Behind the Book: Kathleen A. Sluka
 We asked the editor for her thoughts on this
important new book.
Q: The book includes an overview of the basic science of
pain. Does this information fill a gap in the standard education of the
physical therapist?
A: The basic science mechanisms of pain presented in this book expand on
the normal education physical therapists receive on pain mechanisms. The
book describes the standard pathways for transmission of nociceptive
information in the periphery through to the cortex, which is normally
included in physical therapy education. This information is expanded to
describe the neurotransmitters and receptors involved in nociceptive
transmission peripherally, as well as centrally. In addition, we
describe the neuroplastic changes that occur in the peripheral and
central nervous systems as a result of tissue damage, termed peripheral
and central sensitization. We further emphasize how these basic science
mechanisms underlie clinical pain manifestations, such as referred pain,
hyperalgesia, and allodynia.
Q: Physical therapy has traditionally been involved in
increasing functional ability and movement. Do physical therapy
techniques directly relieve pain as well?
A: The overall goals of physical therapy are to improve functional
ability and movement. These goals can be met by directly addressing
muscle and joint function, as with exercise and manual therapy, but also
indirectly by relieving pain, as with TENS. Several physical therapy
techniques can directly relieve pain by activating inhibitory mechanisms
within the nervous system. These include exercise, TENS, and joint
manipulation. The neurobiological mechanisms by which these techniques
relieve pain are outlined in specific chapters.
Q: What are some of the ways described in this book in which
physical therapists can help patients with chronic pain to improve their
quality of life?
A: The management of chronic pain is difficult for all clinicians. This
book provides the evidence that will allow the therapist to make an
educated choice about treatment. The philosophy we present involves
understanding potential mechanisms that underlie findings in the
assessment of patients, and understanding the mechanisms by which
physical therapy treatments work. For example, if a patient has
significant central sensitization as a result of a pain condition,
therapies designed to reduce central sensitization should be the first
choice. These treatments could be ones aimed at activating the
descending inhibitory system, such as TENS or exercise. The book also
supports a multidisciplinary approach to the management of chronic pain
that can be delivered in collaboration with a team that includes
physicians, nurses, and psychologists. This team approach addresses the
multidisciplinary nature of pain to reduce the sensory as well as the
affective dimension of pain.
Q: Which is more valuable for the patient with acute or
chronic pain: hands-on therapy or education on self-care?
A: There is no single technique that is more valuable for a person with
acute or chronic pain. However, the philosophy of the physical therapy
profession, and for the physical therapy management of pain, is to give
patients the tools to help manage the pain on their own. This approach
includes education on self-care and on appropriate exercise programs for
a given condition. Making the patient an active participant in the care
process through education and exercise is particularly important for
those with chronic pain. Hands-on therapy can be a valuable addition
that can reduce functional limitations and pain to allow the patient to
progress through an active exercise program.
Q: You and your contributors have reviewed the evidence base
for many techniques used today in physical therapy practice. In general,
how well are these methods supported by high-quality evidence? Were
there any surprises?
A: There were few surprises in the findings, with the level of support
varying depending on the pain condition and the treatment itself. There
is very strong high-quality evidence to support the use of exercise in
the treatment of almost all pain conditions. For other treatments,
evidence is beginning to emerge, with higher-quality trials being
published on a variety of pain conditions. There are several newer
studies supporting manual therapy techniques for musculoskeletal pain
conditions, as well as two relatively new meta-analyses to support the
use of TENS for postoperative pain and for chronic musculoskeletal pain.
Studies on the efficacy of physical therapy treatment can be difficult
to design due to the inability to provide an adequate placebo. For
example, how do you provide an adequate placebo for a hot pack or for
exercise? These types of problems will always be inherent in the
experimental design of true randomized double-blind placebo-controlled
trials for many physical therapy treatments.
Q: What is the applicability of physical therapy for pain
relief in developing countries and low-resource settings?
A: Physical therapy is extremely applicable in developing countries and
low-resource settings. Most therapies are inexpensive, and those with
the strongest efficacy, such as exercise, are among the most inexpensive
and easy to administer. Exercise and manual therapy techniques for the
management of chronic pain do not require special equipment and can be
performed in almost any setting. The principles of physical therapy are
clearly to use education and exercise to improve function, which can be
done in any setting.
Q: What is your philosophy regarding the interdisciplinary
management of pain, and what is the physical therapist’s role in a
treatment team?
A: Interdisciplinary management, particularly for chronic pain,
has good evidence to support its efficacy and appears to produce greater
effects than treatment by a sole practitioner. Interdisciplinary pain
management should be considered for every chronic pain patient. The
physical therapist plays a vital role in this team by helping patients
become active participants in their recovery, and by emphasizing an
approach that will improve function.
Q: What are some important research areas for the future of
physical therapy management of pain?
A: Numerous research areas present themselves at both the basic science
and clinical level for physical therapy management of pain. I believe we
need to continue to expand our understanding of the mechanisms by which
physical therapy treatments, such as exercise or manual therapy, relieve
pain. One of our weakest databases involves the use of physical therapy
for neuropathic pain and complex regional pain syndromes, and thus
high-quality randomized controlled trials are needed. We also need to
begin examining, in high-quality trials, the effectiveness of our
treatments not only on resting pain, but also on other outcomes that are
clinically relevant, such as function, pain with function, quality of
life, and return to work. Lastly, combinations of treatments, either
more than one physical therapy treatment or a pharmacological treatment
and a physical therapy treatment, should be explored for enhanced
efficacy. This issue is particularly relevant because most patients do
not receive only one treatment at a time.
Q: Who should buy this book?
A: This book is designed for physical therapy students in a
professional degree program and can serve as a textbook for a course on
pain management for physical therapists. It is also appropriate for
practicing physical therapists who actively treat people with acute and
chronic pain, and for those in other areas of rehabilitation, such as
physiatrists, osteopaths, and occupational therapists. The book would
also be useful for any health professional with an interest in an
interdisciplinary approach to pain management.
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