This post was written by guest author Dr. Mehul J. Desai, the Clinical Assistant Professor at The George Washington University School of Medicine and Health Sciences, Chief – Division of Pain Medicine at Virginia Hospital Center and President of the International Spine, Pain & Performance Center. Dr. Desai has been a leading interventional pain physician and researcher for more than 13 years.
As pain specialists we’re always looking to create individualized pain treatment plans that offer long-term results. In my experience, physical therapy and a relationship with physical therapists (PT) play a key role in this. This is particularly true for patients who are dealing with chronic low back pain or pain in areas like the shoulder or knee where the goals are pain reduction and functional improvement.
My treatment goals are therapy effectiveness and durability. Engaging and creating relationships with other clinicians is vital in this process. Oftentimes physical therapists have deep and meaningful clinical relationships with their patients and are dedicated to help them improve. While I know that stimulating the medial branch in patients with low back pain works, can I extend the longevity of relief and improve function by adding physical therapy? Therefore, when I begin to consider peripheral nerve stimulation, I also in parallel consider physical therapy and working with a PT and developing a comprehensive pain treatment plan.
Prior to an intervention of some kind, many patients are simply unable to actively participate in physical therapy due to pain and dysfunction. After the intervention, the patient may be able to resume physical therapy. If you believe as I do, that low back pain often becomes centralized, making the primary pain generator difficult to assess. Getting and keeping the trunk stabilizers and extensors actively contracting after the pain has started to abate can be important in regard to long term function and prevention of recurrence. As Deer et al have recently elucidated in their recently published PNS mechanistic theory, pain may be brought about and maintained, in part, to the lack of healthy afferent inputs from poorly functioning lumbar extensors such as the multifidus. The physical therapist can help the patient keep these motor systems active in an attempt to reduce disuse, dysfunction and recurrence. As we know, “exercise is health” and your physical therapy colleagues are experts in this area.
In some cases, I have patients who are already working with a physical therapist. In other cases, I’m actually going to recommend physical therapy as part of the treatment plan. Either way, I commonly directly communicate with the therapist regarding the treatment plan, any specific restriction and educate and engage with them regarding peripheral nerve stimulation.
The Big Picture: Engaging a Physical Therapist is an Opportunity for Better Chronic Pain Treatment
Working with physical therapists is actually part of a larger conversation around the question “How do we better engage colleagues that are treating the same person?” It is often easy to become myopic in our treatment approaches, in my opinion, this is a missed opportunity.
As noted, due to the positive relationship most patients enjoy with their physical therapists there is an opportunity for PTs to become much more familiar with the patient’s needs, lifestyle, overall health situation. This ultimately may provide invaluable insight for physicians also treating these patients.
Pain physicians are often incredibly effective at getting their patients from point A to point B. Keeping them there often takes a village. This is where a strong physician-physical therapist relationship is paramount. Speaking to physical therapists as colleagues and partners facilitates the continual improvement of our mutual patients. It takes a siloed approach and transitions it to a comprehensive approach.
Potential Benefits Exist for the Patient, Pain Physician and Physical Therapist
Establishing a working relationship and collaborative dialogue benefits everyone.
From the patient’s perspective, it may help them to feel more confident and comfortable. An approach that is comprehensive and encompasses an understanding of their whole pain journey and lifestyle is more likely to result in patient engagement.
From the physician perspective, establishing a working relationship and dialogue with a patient’s physical therapist enables more effective treatment plans, creates mutually-aligned goals with which to benchmark success, as well as ensuring durable results on behalf of patients.
From the physical therapist perspective, this dialogue may help them to understand how the treatment a patient is undergoing – say for example a 60-day medial branch PNS treatment – may impact the patient short-term during physical therapy, adapt the physical therapy plan to help the patient leverage the best results from the treatment the pain physician has implemented, and finally, to monitoring progress of the patient long-term based on a set of goals designed mutually with the pain physician.
Specifically, collaboration enables more proactive, effective, confident treatment
Beyond the dialogue that can occur before, during and immediately after treatment, establishing a relationship with your patient’s physical therapist can help you and the patient become more proactive about pain treatment as well.
A physical therapist is uniquely situated to be able to advise what the patient is experiencing in terms of limitations in movement and sources of pain, or when something new is occurring. This real-time analysis is key to helping formulate an evolving and effective treatment plan for the patient long-term. And for the physical therapist, learning about what the pain physician is doing will help them to better understand what the treatment is doing, what the impact might be on the patient and their pain, and what limitations it may create for patient in physical therapy during treatment, as well as opportunities to adjust the therapy for greater improvements later on.
Moreover, working together may help provide reaffirmation and confidence to patients regarding their treatment plan, allows the pain physician to have other advocates to create multi-touch communication points to both reaffirm treatment effect and that treatments take time. Further, collaboration may help alleviate doubts a patient may have in the early stages of treatment.
How the Pain Physician-Physical Therapist Relationship Should Work
The key word here is collaborative. The relationship between the pain physician and physical therapist needs to be collaborative, regardless of who has first engaged with the patient. Both parties need to approach each other with the mindset that they are both there are on behalf of the patient and place the patient at the center of the process. While physician-physical therapist partnership are stronger, even stronger are patient-physician-physical therapist collaborations. Pain physicians should especially be mindful of the critical role a physical therapist plays in helping patients achieve improved physical movement and independence and the trust most patients have in their physical therapists.
In general, the pain physician-physical therapist relationship is effective when the following occurs:
- Open and transparent dialogue about the patient’s current health, pain, physical limitations, and progress. Consistency through the patient treatment journey with regular touch points is vital.
- Setting goals for the patient together, including goals each hopes the patient will achieve or accomplish short-term and long-term.
- Discussing the pain treatment (stimulation, PNS, etc.) the pain physician as well as those that the physical therapist will implement and what effects it will have on the patient during the treatment duration time itself, as well as post-treatment. This includes identifying limitations for the patient’s physical therapy and overall physical activity during treatment as well as for a foreseeable time after (e.g., 2 weeks).
- Discussing how physical therapy may help the patient to achieve the goals outlined above, as well as the specific benchmarks the physical therapist will watch for to indicate progress. This includes specific things the physical therapist and pain physician have decided on together to watch for post-treatment.
- Developing a comprehensive treatment approach that leverages the expertise of the pain physician to relieve chronic pain and the expertise of the physical therapist to achieve improved function, physical movement, strength, and independence.
Example: How I work with a physical therapist on a patient
To give an example of this relationship, here’s how I approach working with a physical therapist for a patient I am advising peripheral nerve stimulation treatment for:
- I strongly recommend to the patient that they work with a physical therapist.
- I call the physical therapist on behalf of the patient to initiate an open dialogue mentioned above. In this conversation, I usually detail the pain symptoms the patient is experiencing, the impact the pain is having on their physical and functional well-being, explain why I recommended physical therapy to the patient, what limitations the patient may have currently as well as post-treatment, and the goals I have for the patient.
- In 2 weeks or so, after treatment has been implemented, I’ll be looking to re-engage in another conversation with the physical therapist. In this conversation, I’m looking for the PT to share their views on the patient’s overall performance and how the treatment is working in relation to the pain the patient was experiencing and the goals we outlined in the first conversation.
- Following this, there may be additional conversations as treatment concludes or progresses, and we work together to evaluate the positive results for the patient’s pain relief and improved physical well-being.
Apply a Collaborative Care Model for Chronic Pain
Pain physicians and physical therapists, we have complimentary goals. We’re focused on creating a healthier, happier patient by improving physical health and well-being. How we treat the patient may be different, but our methods collectively work to enable more sustainable results. Our methods are symbiotic.
With every patient I consider how physical therapy might play a role in creating long-term results. Pain treatment is not a one-step journey, but one that requires a personalized omni-channel approach and the ability to adapt and evolve over time. Collaboration with colleagues is a pivotal piece of this.
If you’re not already leveraging physical therapy and the close collaborative relationship possible by engaging with a PT, I highly recommend considering it. The benefits to your patients are numerous.
About Dr. Mehul Desai
Mehul J. Desai, MD, MPH, is the Medical Director of the International Spine, Pain & Performance Center and Chief, Division of Pain Medicine at Virginia Hospital Center. A board-certified physician, Dr. Desai provides comprehensive care using cutting-edge technologies for a number of pain conditions. He has received extensive training in pain medicine and physical medicine and rehabilitation, and in addition to his roles mentioned above, he also holds the following titles and responsibilities: Director, Interventional Spine and Musculoskeletal Medicine Fellowship (NASS); Medical Director, the Performance Lab; President, Monument Research Institute; and Clinical Assistant Professor, Department of Anesthesiology & Critical Care, George Washington University, School of Medicine.