ࡱ> B1=>?@ADE@AZU|7 bjbjUU i7|7|أyl&B N (((8`t p:(".E DO$q @E. 8.4'S \. | . >(X ,\$%0D \b" fForeword The field of chronic pain has received increasing interest in the last few years. Questions regarding the treatment and care of chronic pain are at the forefront of the field of physical therapy. Further interest has been developed into possible preventative measures progressive nature of the syndrome. Clinical observations have encouraged the investigation for techniques to intervene in the development of chronic pain. Treatment techniques are constantly being studied and assessed for clinical effectiveness. A momentary view of this development will serve as an indicator for the future of the field. Acknowledgements This paper could not have been realized without the visionary assistance, sage guidance and copious support of Bernadet Smetsers and David de Louw. Their instruction, advice and encouragement assisted us in long days spent in the creation of this paper. The background knowledge imparted by Frank Verhulst, Jan Rumpt and Alexander van Doorn served us a solid foundation to build our research upon. Paul de Meurichy, as our tutor, has been unremitting in his support for us enduring the challenges of life abroad. The staff in the Library at Fontys Hogescholen Eindhoven was always genuinely helpful with their advice and understanding. Our families, for whom it can truly be said this wouldnt have been possible without, have stood next to us through the dark days, behind us in the glorious times and ahead of us when we needed their direction. Our appreciation is beyond words. The friends we have made, who trudged with us through the trenches will always have a warm place in our hearts. Abstract Background: Chronic pain affects a large proportion of the population. A global consensus among physiotherapists and other health professionals is lacking in the definition, assessment, prevention and treatment of chronic pain. Objectives: The aim of this systematic review was to determine a concise definition of chronic pain, gather valuable assessment tools for a proper diagnosis and to develop a treatment plan based upon pain and functional disability to increase the quality of chronic pain prevention and management. Search strategy: Medline, PEDro, Cochrane reviews, CINAHL, physiotherapy and pain organizations WebPages were searched. Selection criteria: Systematic reviews, randomized controlled clinical trials (RCTs) and literature from texts and WebPages that described the definition, treatments and assessments for physiotherapy of chronic pain. Main results: There is strong evidence that exercise therapy is the most effective treatment for chronic pain. Manual therapy and Hydrotherapy may also play a secondary role. Conventional Physiotherapy such as modalities (electrotherapy, heat, cold and ultrasound), massage and traction have insufficient evidence to justify their use in chronic pain treatment. There is further evidence to support that the combination of psychological treatments with physiotherapy can lower the risk of a long-term disability developing. An emphasis on the reduction of pain only re-directs the attention of the patient away from functionality. Therefore treatment must focus on functional activities directed at improving the patients participation in society. Introduction Above all, do no harm- Hippocratic Oath Problem Definition Physiotherapists are on the front lines of a health care system that is, undeniably, developing chronic pain patients. Despite all the well-intentioned aims of healthcare, some patients conditions grow precipitously worse. Their acute conditions become chronic unending struggles. The impact of chronic pain is severe on the individual, their family and on society. This problem has been described as The 20th century medical disaster (Waddell, 1998). The economic impact on society in the United States alone is estimated to be in excess of $85 billion US dollars (Dunegan, 2001). Companies struggle with policies to adequately cope with the chronic illness in workers who are not able to return to their jobs. Families are forced to endure the difficulty of adjusting their lives to take care of an afflicted family member. Individual patients must cope with a health care system that fails to provide answers while enduring the cruelly incessant nature of chronic pain. Regrettably, the physiotherapist and other allied health professionals can unintentionally guide patients toward chronic pain. Using an inadequate model of treatment leaves the consideration of the patients social circumstances out of the equation. Without considering these peripheral factors, physiotherapy can reinforce potentially perilous behavior patterns. Fortunately, the physiotherapist can steer the patient away from this dire outcome as well. With careful assessment, treatment planning and interviewing with the patient steps can be taken to prevent chronicity. While the prophylaxis is not guaranteed, the need for improvements to current standards exists. There is no global consensus for the definition, assessment and treatment of chronic pain. While areas of expertise exist in individual countries a common consensus has yet to be reached. Educational material in this field is grossly insufficient, creating a need for material to train the next generation of health professionals. While technical aspects of the curriculum are currently stressed, the intervention for social well being is not being properly emphasized. As student populations become increasingly diverse, the importance of multi-cultural approaches to social concerns also increases. Objectives of Research In order to provide greater insight into the physiotherapy intervention of chronic pain a series of objectives for the research have been established. The investigation will explore various aspects of chronic pain and how it is confronted in the field of physiotherapy. There exist several definitions of chronic pain, varying between cultures and medical disciplines. A common generally appropriate definition for chronic pain will be established in this paper. The importance of gathering a multinational perspective on chronic pain will be accentuated in the performance of our research. A discussion will be present on the best interpretation of these results. To find effective techniques in the assessment of chronic pain various tools will have their statistical validity shown. The evidence of this will be procured through a systematic review. The assessment methods used have been selected on the basis of providing insight into a variety of aspects of the patient. The results will illustrate our findings on the statistical relevance followed by an examination of the assessment tools with respect to contrasting models of healthcare. As in the definition, the inclusion of material from a variety of countries will be stressed. For the treatment section, again a systematic review will be executed in order to compare the effectiveness of physiotherapy interventions. The areas of treatment emphasized in the assessment section will be used as the structure of the treatment interventions selected for analysis. A comparative study will be done concluding in recommendations of the optimal interventions available. Global interpretive findings and recommendations will be the concluding chapter. Recommendations of clinical relevance, as well as those based on scientific evidence will be made for the physiotherapist. Interventions that have shown to be effective will be discussed as well as those areas where there is a need for further research. Thesis of Paper Chronic pain can be prevented by maintaining a multi-faceted approach to physiotherapy management of acute pain. With a concise definition of chronic pain and insightful application of various assessment tools, accurate intervention and diagnosis can be made. Establishing a treatment plan based upon pain and functional impairments increase the quality of patient rehabilitation. Outline of chaptersCh. 1 a concise definition of chronic pain is discussedCh. 2 a description of various assessment tools is providedCh. 3 treatment techniques and strategy are consideredCh. 4 a general discussion of research and recommendations are made Chapter 1.0 Definition of Chronic Pain Introduction A definition provides the foundation for understanding a subject matter. When the issue is illusive assigning a firm, clear definition allows for the reader to build knowledge and understanding. As a starting point for chronic pain a clear definition will allow for clarification of the objectives of further research. A well-formulated definition is clear and concise giving the reader a solid foundation on which to form further opinions. The definition of chronic pain is needed to give a vantage-point and provide illumination on the basic elements of chronic pain. This search also represents the illusive nature of the subject matter. This will provide a clearer understanding of the topic matter for further discussion of more technical aspects. For an increased familiarity with the differences between acute and chronic, a description of each will be provided. Analysis of the results will form a specific definition acceptable throughout the treatment of chronic pain. 1.0.1 Objectives of Research of Chronic Pain To find and/or generate a common, universally applicable definition for chronic pain which can be applied to the studies of prevention, assessment and treatment of pain. An emphasis will be placed on a multi-national origin for the accepted definition. 1.1 Data Collection and Analysis The research was performed with the following structure established. This structure allowed for a clear and reasonable search to be conducted. The criteria were selected through consensus of the reviewers before the initiation of the search. Also the strategies were chosen to create an accurate and concise search. The selection of references reflects the background knowledge of material established before the realization of the project. 1.2 Selection Criteria The four reviewers utilizing researched definitions identified during the search for consideration. The definitions were then identified for utility and significance on the basis of contemporary relevance, applicability to physiotherapy and clarity. Table 1. Selection Criteria for DefinitionContemporary RelevanceApplicability to physiotherapyClarity Pertinent definitions were discovered using International pain organization websites, journals and medical dictionaries. Website queries were done generally using Google and specifically to organizations web sites. Table 2.The terms searched-Chronic Pain-Acute Pain -Definition of Chronic Pain-Definition of Acute Pain References for the definition of chronic pain were outlined before the search as: The Textbook of Pain by Melzack and Wall, 1988 Tabers Medical Dictionary 1999 International pain organizations American Pain Society;  HYPERLINK "http://www.ampainsoc.org" www.ampainsoc.org Canadian Pain Society;  HYPERLINK http://www.canadianpainsociety.ca www.canadianpainsociety.ca International Association for the Study of Pain; www.iasp-pain.org Table 3. Search SummaryTerms SearchedReferences UsedConsideration Criteria1. Chronic Pain (Definition of Chronic Pain)1. Tabers Medical Dictionary1. Contemporary relevance2. Acute Pain (Definition of Acute Pain)2. International Association for the Study of Pain2. Applicability to Physiotherapy3. Sub-acute Pain (Definition of sub-acute)3. American Pain Association3.Clarity of definition4. Canadian Pain Society 1.3 Results Table 2 below represents the results of our research. Not all terms of the search were found in every source selected. As well, not every source provided information on the term selected. Table 4. Results of ResearchTerms SearchedTabers Medical DictionaryInternational Association for the Study of PainAmerican Pain SocietyCanadian Pain SocietyChronic Pain (Definition of Chronic Pain)Chronic= describing a disease of long duration involving very slow changes. Pain= An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Chronic Pain which includes persistent (ongoing) and recurrent (episodic) pain with possible fluctuations in severity, quality, regularity and predictability. Pain lasting longer than six months; or of a duration longer than the expected time to tissue healing or resolution of the underlying disease process; or due to a condition where there is ongoing nociception.Acute Pain (Definition of Acute Pain)Acute= describing a disease of rapid onset, severe symptoms, and brief durationNone foundAcute pain follows injury to the body and generally disappears when the bodily injury heals. None foundSub-acute Pain (Definition of sub-acute)Describing a disease that progresses more rapidly than a chronic condition but does not become acute.None foundNone foundNone foundMelzack and Wall provided further less confined reference information. Historical references and physiologic processes were gathered from the search in their text. The application of our selection criteria validated all the terms found in the search. From these results an interpretation and discussion of a collective definition will be made. Six resources were located and all six were included for consideration in the formation of a common definition. 1.4 Discussion Pain has been explored and examined at length with varied viewpoints and definitions. In order to gain a clear understanding of chronic pain, a difference needs to be drawn between the acute and chronic forms of pain. The systems, onset and development of both give interesting insight into the varying nature of the two types 1.4.1 Acute Pain Acute pain is often described as pain of lasting 3 to 6 months' duration for which an underlying pathology can be identified. Tissue inflammation, damage, or destruction is often related somatically, or in a referred distribution, to the location and intensity of the person's pain report. The pain is well localized and defined by the patient. Medication intake and other medical interventions usually are appropriate for the degree of pathology identified. (Melzack and Wall, 1988) Acute pain is mediated through pathways that include rapidly conducting systems, such as the dorsal column post-synaptic system, spinocervical tract, and neospinothalamic tract. Acute pain is also associated with increases in muscle tone, heart rate, blood pressure, skin conductance, anxiety and other manifestations of increased sympathetic nervous system activity. (Melzack and Wall, 1988) Table 5. Acute pain definitionWell localized pain from a specific identifiable pathology, lasting no longer than 6 months 1.4.2 Chronic pain In contrast, chronic pain appears to be mediated through slowly conducting fibers in the spinothalamic tract and reticular formation and is often associated with insomnia, loss of appetite and libido, and feelings of helplessness and hopelessness, rather than with increased sympathetic nervous system activity. The therapist needs to maintain vigilance for the development of chronic pain as early as six weeks (early in the sub-acute stage (sub-acute describes a disease that progresses more rapidly than a chronic condition but does not become acute)) into the healing process. This ensures the pain does not reach an intractable nature during the rehabilitation process. The difficult process of chronic pain may be already in place at the three-month mark. Therefore, primary and secondary prevention are no longer feasible strategies in the management of the patient.  EMBED Word.Picture.8  Figure 1 Three-phase model of back pain Given the nature and variety of chronic pain and its manifestation in-patients, the need of a common definition is clear. Through the study of chronic pain many definitions have been proposed. While some have received greater attention and acceptance than others, a broad examination provides a useful illustration of the field. The first widely accepted definition of chronic pain was presented by Bonica in 1959. (Melzack and Wall, 1988) Chronic pain is pain which persists past the normal time of healing this may be less than one month, or more often, more than six months. Definitions provided by various pain societies reflect a common meaning with varying emphases. The Canadian Pain Society (CPS) generally defined chronic pain as: Pain lasting longer than six months; or of a duration longer than the expected time to tissue healing or resolution of the underlying disease process; or due to a condition where there is ongoing nociception. CPS further makes a clear distinction between chronic pain of a cancerous origin and non-cancer related. The International Association for the study of Pain (IASP) settled on three months as the dividing line between acute and chronic pain (Merskey, 1986). Reaffirming these definitions the American Physical Therapy Association describes chronic pain as Pain lasting longer than 6 months in duration. An underlying pathology is no longer identifiable and may never have been present. Table 6. Definition of chronic painPain which exceeds the normal tissue repair period in excess of three to six months 1.5 Conclusion From these various sources it can be concluded that chronic pain is pain which exceeds the normal tissue repair period exceeding the range of three to six months. It is clearly distinguished from acute pain through its the duration. Its development is slower and the prognosis is more difficult to determine. As a physiotherapist exposure to acute pain is constant. As a physiological response to patients pathologic condition it is an accepted part of treatment. With the definition made, vigilance for chronic pain can be maintained. Understanding that chronic pain does not have a set time period (such as three months) and it may start as early as three weeks into the treatment program, will enable the therapist to more effectively screen for warning signs of chronic pain. It needs to be acknowledged that pain is only a symptom and that ability is a truer measure of the patients restricted function. Even if the definition of chronic pain is made, it should not be seen as the sole means of assessing a patients condition. Chronic pain needs to be viewed with regards to the limitations experienced through the patient. This functional vantage-point will allow for a more successful recovery of the patient. The screening process involves recognizing the differences in behavior and presentation between physiologic and pathologic pain conditions. The tools and methods which can make this more effective are the topic of the proceeding research review. The definition gained should be kept in mind when interpreting the findings of the research. Chapter 2.0 Assessment Methods Introduction With an international definition for chronic pain, medical health professionals will be more able to find the most effective and accurate techniques for diagnosing and preventing the development of chronic pain patients. This chapter is a systematic review of modern research that is needed to show the reliability and validity of the assessment tools used in identifying patients with chronic pain. There are many assessment tools that have been developed by various researchers for the diagnosis of chronic pain. These assessment tools should address the pain intensity that the patient experiences, the functional disability of the patient and the psychological issues that may cause a patient to develop chronic pain. The objective of this chapter is to determine which assessment tools are most effective in the diagnosis and prevention of chronic pain. 2.0.1 Objectives To find the most effective and accurate technique for diagnosing chronic pain patients in the field of physiotherapy internationally via a systematic review of modern research. 2.1 Data Collection and Analysis Different search terms were used that were thought to be most applicable for the study of the prevention and diagnosis of chronic pain with physiotherapy. The terms used in the search were: Chronic pain Physical Therapy/Physiotherapy Diagnosis of Chronic Pain Intervention/treatment of Chronic pain Pain management Allied health journals, physiotherapy organizations from western countries, health related databases and international health care organizations were used as research sources for gathering evidence. The five search terms given above were used for all the sources given below: Physiotherapy organizations web pages from the following countries Australia Canada New Zealand United Kingdom United States Medline Cochrane Library CINAHL Pain organizations websites and disseminated information Previously established journal sources 2.2 Selection Criteria The material obtained from the above sources will be analyzed using the following inclusion criteria: Provides characteristics, symptoms and/or signs for the prevention and diagnosis of chronic pain in physiotherapy Articles or material must adhere to the scientific standards for research and publication. The articles of research used will be systematic reviews and/or random controlled clinical trials (RCTs). Provides international perspective on the prevention and diagnosis of chronic pain patients in physiotherapy. Table 1. Search Summary for Assessment MethodsTerms SearchedSourcesConsideration Criteria1. Chronic pain1. Medline1. Provides characteristics, symptoms and/or signs for the diagnosis of chronic pain in physiotherapy 2. Physical Therapy/ Physiotherapy2. Cochrane Library2. Describes modern, clear, multidisciplinary interventions for chronic pain patients with the main focus being on physiotherapy. 3. Diagnosis of Chronic Pain 3. CINAHL3. Articles or material must adhere to the scientific standards for research and publication4. Pain management4. Pain organizations websites and disseminated information4. Provides international perspective on the diagnosis and intervention of chronic pain patients in physiotherapy. 5. Intervention/treatment of Chronic pain5. Previously established journal sources6. Physiotherapy organizations web pages from the following countries -Australia -Canada -New Zealand -United Kingdom -United States 2.3 Results There are many types of assessment tools that have been developed by researchers for the prevention and diagnosis of chronic pain patients. However not all the available assessment methods are reliable, valid, cost-effective, easy to use, and sensitive/specific to the chronic pain patient. The results from the data collection, analysis, and selection criteria given above in sections 2.1 and 2.2 should be able to show in this study, which assessment tools are most effective for physiotherapists to use in the prevention and diagnosis of chronic pain in their patients. In the search for various assessment tools to be used in the prevention and diagnosis of chronic pain by physiotherapists, there were forty-two sources found. The sources that were used are stated above in Section 2.1 Data Collection and Analysis. Of the forty-two sources that were found to relate to chronic pain and physiotherapy, only eighteen sources were determined to be able to be included in the study, according to the criteria given above in Section 2.2 Selection Criteria. Therefore twenty-four sources of information were rejected from consideration because they did not follow the Selection Criteria given in Section 2.2. According to the selection criteria given in Section 2.2 six clinical assessment tools, questionnaires and guidelines were selected to be used for the prevention and diagnosis of chronic pain patients by a physiotherapist: Overt Pain Behavior Pain Drawing Visual Analog Scale (VAS) Pain Disability Index (PDI) Multidimensional Pain Inventory (MPI) New Zealand Guidelines to Assessing Yellow Flags 2.3.1 Overt Pain Behavior Guide The assessment of a chronic pain patient is a very subjective procedure and may lead to observer bias by the physiotherapist. To try to prevent observer bias Keefe and Block (1982) have developed a much better guide for patient observation. The guide is based on five separate pain behavior characteristics that a chronic pain patient could exhibit: guarding, bracing, rubbing, grimacing and sighing. The attitudes and actions of chronic pain patients are often presented in an open and obvious way, and for this reason the tool is called Overt Pain Behavior. According to Waddell and Richardson (1992) clinical observation of overt pain behavior can provide useful additional information about illness behavior in low back pain. Reliable observations can be achieved in a carefully standardized research situation but in routine clinical practice are vulnerable to considerable observer error and bias. Mastering the use of the overt pain behavior guidelines requires careful training and standardized methods of observation (Waddell 1998). Table 2. Overt Pain Behavior (Keefe and Block 1982)Guarding abnormally stiff, interrupted or rigid movement while moving from one position to anotherBracing a stationary position in which a fully extended limb supports and maintains an abnormal distribution of weightRubbing any contact between hand and back, i.e. touching, rubbing or holding the painful areaGrimacing obvious facial expression of pain that may include furrowed brow, narrowed eyes, tightened lips, corners of mouth pulled back and clenched teethSighing obvious exaggerated exhalation of air usually accompanied by the shoulders first rising and then falling. They may expand their cheeks first. 2.3.2 The Pain Drawing The simplest example of pain behavior is the pain drawing (Ransford et al 1976). Patients often show eagerness in recording their pain on an anatomical outline. Patients regard it as a simple question about their pain. The way that is used to describe the pain gives insightful information into how they are reacting and about how the pain is affecting them. The pain drawing describes the pain, but the way the patient draws their pain can also provide a great deal about their psychological state. The simplest signal is the quantity of drawing - how large an area and the density with which they fill it in. All of the features of the drawing provide insight into the patients psychological state. Most pain drawings include both physical and psychological information, though one usually dominates the other. (Ohlund et al 1996) Commonly, hash marks (///) are used to indicate pain, circles (000) represent pins and needles, Xs (XXX) represent ache and horizontal lines (===) depict numbness.  Figure 1. The pain drawing In figure 1., patient A and patient B both suffer from a prolapsed disc at the level of S1. Patient A represents their pain and paraesthesia anatomically for S1 distribution. Patient B is not a paraplegic, though the illustration shows the realization is much greater. The insight into the psychological state of Patient B is much more evident. The pain drawing is a stable and reliable instrument for use with chronic pain patients (Chan et al. 1993, Ohnmeiss 2000, and Rantanen 2001). The test-retest repeatability of patients using the pain drawing more than once for the analysis of chronic back pain was consistent in completing the drawings (Ohnmeiss, 2000). The results of this study by Ohnmeiss (2000) supports that the pain drawing is a stable instrument for use in chronic back pain patients. In a chronic low back pain study of 114 low back pain patients classified according to the Quebec Task Force were compared with 50 patients with different pain syndromes but without apparent low back pain. In this study the sensitivity of pain drawing was excellent but specificity was low: 47% for men and 39% for women (Rantanen, 2001). 2.3.3 Visual Analog Scale (VAS) A common and popular report of a patients perception of their pain is the visual analog scale (VAS). This method uses a direct scaling technique to provide a continuous scale for magnitude estimation. It is scored by measuring the distance from a base point (0cm) representing no pain to the point marked by the patient from the possible maximum score (10cm). The patient uses the unmarked 10cm line to indicate their pain with a pen. The therapist measures the number of centimeters with a ruled line from zero to determine a score from 0 to 10.  No pain Extreme Pain Figure 2. Visual Analog Scale (VAS) A frequently used variation of this scale is a verbal assessment of the experiences. The VAS score is used as an accurate measure for intensity and unpleasantness of pain. Through research the scale has been found to have a high test-retest reliability coefficient (r=. 97). Interestingly, the validity coefficient for chronic pain patients was lower (r=. 70) (Huskisson, 1987). The study by Wade et al. (1990) sought to determine the relative contribution of frustration, fear, anger and anxiety, to the unpleasantness and depression that chronic pain patients experience. Seven visual analog scales were used in the study to measure the degree of emotional unpleasantness, pain intensity, anxiety, frustration, fear, anger and depression. The test-retest reliability coefficients were significant for the negative feeling VAS that gave an average reliability coefficient of 0.82 2.3.4 Pain Disability Index (PDI) The physiotherapist needs to obtain information regarding the functional limitations of the patient from the employed examination. The Pain disability Index (PDI) provides brief and functional insight into a patients limitations in the areas of: Family/home responsibilities Recreation Sexual behavior Social activity Self-care Life support Occupation This is particularly valuable to the physiotherapist in evaluation, treatment and progress related to the functional ability of the patient. It provides a basis to set goals and document progress of the patients treatment. (Hankin, 2001) In this self-reporting index the patient is asked to rate their level of disability on the scale of zero to ten (zero being no disability and ten being total disability). The score correlates positively to the disability experienced by the patient. The PDI is reliable and valid to be used as a tool for the assessment of subjective pain-related disability in patients with chronic pain (Jerome & Gross 1991; Strong, Ashton & Large 1994; Tait et al 1990). The PDI has been found to have a high degree of internal reliability and a high alpha reliability coefficient of 0.87 (Tait et al 1990). In a study by Strong, Ashton & Large 1994 the reliability and validity of the PDI were evaluated (r=0.76) in patients with chronic low back pain. The PDI score in the study was found to be sensitive to functional status differences within the patient sample. Patients with high PDI scores reported more psychological stress (P less than 0.001), more severe pain characteristics (P less than 0.001), and more restriction of activities (P less than 0.001) than patients with low PDI scores (Tait et al 1990). The PDI is a useful tool in providing important information on functional disability beyond what is provided by a simple measure of pain intensity (Gronblad et al. 1993; Jerome & Gross 1991; Strong, Ashton & Large 1994; Tait et al 1990). 2.3.5 Multidimensional Pain Inventory (MPI) The Multidimensional Pain Inventory developed by Kerns, Turk & Rudy (1985) is a self-report survey directed towards the relation between cognitive, affective and behavioral dimensions of chronic pain. (Appendix 7.1) The need to integrate physical findings, behavioral manifestations and loss of function is stressed through this survey (Waddell, 1998). The statistical information regarding the reliability and validity of the MPI has not been studied (or published) to date. It consists of 61 questions requiring about 20 minutes to complete. The survey is brief, easy to score and has relevance in various clinical settings. Nine scales are used to place the patient in three patterns, or patient profiles. The scales are: pain severity, interference, life control, affective distress, support, perceived punishing, distracting and solicitous responses from a significant other, and general activity levels. (Hankin, 2001) The three profiles used to classify the patient are Dysfunctional profile, Interpersonally distressed and Adaptive Coper. 2.3.5.1 Dysfunctional Profile The dysfunctional profile is best described with higher than average scores on pain severity, interference and affective distress scales while receiving lower than average scores in life control and general activity scales. This classification is characterized by difficulty in coping with pain and its interference with their lives. 2.3.5.2 Interpersonally Distressed Patients classified as Interpersonally distressed has a high score in the punishing response scale and lower than normal scores in social support, solicitous response and distracting response scales. Difficulty in relationships with others is a typical characteristic of this group. 2.3.5.3 Adaptive Coper The Adaptive Coper profile is determined with a higher than average score in life control scale and below average scores in pain severity, interference and affective distress scales. These patients are coping well with their current situations. 2.3.6 New Zealand Guidelines to Assessing Yellow Flags The New Zealand Guideline Groups (NZGG) 1998 Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain: Risk Factors for Long-term Disability and Work Loss (APYF) details a proposed plan for psycho-social yellow flags in the assessment and treatment of acute low back pain (figure 3.). This guide was developed from a comprehensive publication Clinical Practice Guideline- Acute Low Back Problems in Adults: Assessment and treatment, which was distributed by the Accident Rehabilitation & Compensation Insurance Corporation of New Zealand (ACC) and the National Health Committee in January 1996. The outline represents the combined efforts of various professional groups, through contributions and hearings. The APYF provides a summary of risk factors for long-term disability and work loss, and gives a layout of methods to assess these. Prevention of chronic pain and disability is the target of identifying those patients at risk through appropriate early management. The yellow flags used in the guidelines are psychosocial factors that are likely to increase the risk of a patient with an acute condition becoming a chronic pain patient. The list of yellow flags and assessment questionnaire are appendices 7.2 and 7.3, respectively. 2.3.7 Summary of Results for Assessment Methods The summary of the results for the six assessment methods that were studied for the prevention and diagnosis of chronic pain are presented below in Table 3.  Figure 3. Guide to Assessing Psychosocial Yellow Flags ValidityReliabilityUtilitySensitivitySpecificityAssessment MethodTable 3. Assessment Tools ResearchNo Statistical EvidenceNo Statistical EvidenceCost Effective Some training requiredNo Statistical EvidenceNo Statistical EvidenceOvert Pain Behavior GuideNo Statistical EvidenceNo Statistical EvidenceEasy to use Cost effective Quick to administerExcellent (Rantanen, 2001)47% for men, 39% for women (Rantanen, 2001)Pain Drawing R=0.70 (Huskisson, 1987)R=0.97 (Huskisson, 1987)Easy to use Familiar to patients Quick to administerNo Statistical EvidenceNo Statistical EvidenceVisual Analog ScaleR=0.76 (Strong,Ashton & Large 1994)R=0.87 (Tait et al, 1990)Provides Functional Limitation Insight No Statistical EvidenceNo Statistical EvidencePain Disability IndexNo Statistical EvidenceNo Statistical EvidenceTime intensive for both patient and physiotherapistNo Statistical EvidenceNo Statistical EvidenceMultidimensional Pain InventoryNo Statistical EvidenceNo Statistical EvidenceProvides Indicators for chronic pain prevention Cost effectiveNo Statistical EvidenceNo Statistical EvidenceNew Zealand Guidelines to Assessing Yellow Flags 2.4 Discussion Gaining a better understanding of the patients' pain can be as deceptive and difficult as defining pain itself. The degree, type and frequency of pain can be described in myriad ways, causing confusion and miscommunication between the patient and clinician. The multi-dimensional nature of pain creates a need for clarification of the patients condition from many perspective fields. The importance of a clear impression of the functional limitations of the patients pain and the validity and reliability of the assessment method used indicates the criteria for a practical diagnostic tool. Varieties of forms both short and long, are designed to assist the patient in communicating their symptoms to the therapist. Further standardized clinical assessments for implementations by the clinician have been developed. It is important for the therapist to gain insight into both the patients experiences of pain and the limited functional capabilities. Health professionals that deal with chronic pain patients may base their approach on the disease model or the biopsychosocial model. These two theoretical models may be used as the root of the assessment of a chronic pain patient. Of further importance is recognizing the psychosocial state of the patient is inherently displayed in all descriptions given by the patient through the clinical assessments, questionnaires and guidelines. 2.4.1 Psychosocial State The term psychosocial refers to the interaction between the person and their social environment, and the influences on their behavior. The social environment is composed of family members, friends, and work colleagues, employers, the insurance providers and health professionals. Each member of this group has the potential to affect a patients condition. The interaction of these parties may influence behavior, levels of distress, attitudes and beliefs and subjective experiences of pain. Well-intended actions can inadvertently lead to counterproductive results. 2.4.2 Disease Model vs. Biopsychosocial Model Two models have been used, historically, in the theoretical approach to medical treatment. The Disease model has offered a linear approach with simple relations between the symptoms and treatment (Waddell, 1998). The biopsychosocial model of back pain and disability (figure 4.) emphasizes the interaction between multiple factors (Waddell, 1998). 2.4.2.1 The Disease Model The most common and simplest theoretical model for treatment a medical condition has been the disease model. In this model a clear linear connection is made between the symptoms exhibited by the patient, deducing the pathology, employing a physical therapy and expect a cure (Waddell, 1998). The obtuseness of this mode does not allow for consideration of the social circumstances of the patient. Clearly a more insightful perspective must be achievable through a clinical model. Table 4. The Disease Model1. Identify symptoms2. Deduce the pathology3. Employ a therapy4. Expect a cure 2.4.2.2 The Biopsychosocial Model An applicable model must take into account, physical dysfunction, beliefs and coping, distress, illness behavior and social interactions. These factors allow for a careful, thorough consideration of the pain experience and patients disability. The biopsychosocial model offers a more realistic view of the interactions making up the expression of pain. 2.4.2.2.1 Physical Dysfunction The physical dysfunction is represented in various levels of stress and demand, and the musculoskeletal systems ability to cope to these. In other words, it may occur in structurally sound tissues. These sound tissues may have pain provoked from a pattern of muscle movement, forces, posture or joint movement abnormalities. Segmental changes may arise from neurophysiologic and psychophysiologic problems. In figure 4., this is referred to as Pain. 2.4.2.2.2 Beliefs and Coping The beliefs and coping strategies of the patient are equally as influential on the patients' realization of pain. Anticipation, anxiety and depression, understanding of the pain, prior conditioning and placebos all play a tremendous role in the perception of the pain. Philips and Grant (1991) found that the predominant emotion described by patients with non-specific low back pain was frustration. Other frequently observed emotions were depression and anxiety accompanied by behavioral disruption. Phillips (1998) did another study, which reaffirms the emotional and cognitive relationship to pain. The results indicated that irrespective of the focus of pain, induction of relaxation over a 20-minute period led to significant and sizeable reductions in both sensory and affective pain experiences. The overall intensity of pain was significantly reduced. Coping strategies, whether active or passive, will also be a factor in a patients expressions of pain. Important to note here is the difficulty in changing these thoughts and behaviors once they have been established. The importance of this will carry over in the explanation of prevention and treatment techniques. In summary, fear of pain and what we do about pain may be more disabling than back pain itself. Diagramatically, it is referred to as Attitudes & Beliefs and Psychological Distress. 2.4.2.2.3 Social Interactions Different social settings will elicit different pain and disability behaviors. The interactions with family, work and social networks influence how pain behavior develops. The compilation of these elements is realized in the Biopsychosocial model. As explained by the model, development of chronic pain and disability has the following characteristics: The symptom of pain arises from a physical process of nociception The key to chronic pain and disability may be failure to recover, as it should, rather than the development of a different syndrome. As pain becomes chronic, attitudes and beliefs, distress and illness behavior play an increasing role in the development of chronicity and disability. This all occurs within a social context and leads to social interactions with others, including in particular family, work and healthcare. This represents the Illness behavior and Social Environment portions of the model.  Figure 4. The biopsychosocial model The biopsychosocial model (figure 4.) illustrates a number of important features. It is a model of human illness, rather than pain alone. Pain may arise from nociception anywhere in the body, but its clinical expression involves all of these other aspects. Patients and health professionals alike see that physical symptom as if through a series of filters. When we observe its final clinical presentation, we can only look directly at behavior, which we must analyze more carefully to infer underlying events. (Waddell, 1998) Clinical studies have shown that treating chronic pain as if it were a new episode of acute back pain can result in exacerbation of disability. Relying on a narrow medical model of pain and emphasizing short-term palliative care, with no long-term perspective plan of care will increase the likelihood of chronic pain development (NZGG, 1998) 2.4.3 Clinical Assessment Tools In order to obtain a general impression of the patients pain experience and disabilities the therapist should order the surveys in a way that is appropriately time consuming and provides the insight into the patients condition. It should not be overlooked that the patients psychological state is expressed in the communication of their experience of pain and disabilities. Clinical assessment tools in such as the Overt Pain behavior Guide and the Pain Drawing in general have a number of attributes and drawbacks that need to be considered by the practitioner. Knowledge and understanding of the implementation involved in each is essential. The New Zealand Guidelines Group outlined their advantages and drawbacks as: Table 5. Advantages and Disadvantages of Clinical Assessment ToolsAdvantagesDisadvantagesClinician can adapt readily to characteristics of the individualPotentially time consumingIncorporates clinical experienceMay result in confused picture unless clinical skill level is adequateFacilitates establishing potential goals for interventionPossibility of observer bias or prejudice advantages of combinations of questionnaires with clinical assessmentsLess susceptible to confounding factors, such as social desirability or impression managementImproved accuracyJudgments about severity can be madeClinician can integrate quantitative information with clinical dataCan use two-stage process with questionnaire as first stage filter to target clinical assessments disadvantages of combinations of questionnaires with clinical assessmentsRequire more resources, including the need for adequate organization and trainingMore time needed, potential for delays 2.4.3.1 Overt Pain Behavior Guide The Overt Pain behavior Guide is a general assessment tool that any type of medical professional may use when assessing a patient. This guide was not specifically developed for physiotherapists in their assessment of patients. However it is a valuable instrument that all physiotherapists should keep in mind when assessing a chronic pain patient. The five separate pain behavior characteristics: guarding, bracing, rubbing, grimacing and sighing may alert the physiotherapist that further assessment of the patient is needed to determine if the patient is a chronic pain patient or at risk of becoming a chronic pain patient. The physiotherapist does not ask the patient about these characteristics but only observes the patient and takes note if any of the five overt pain behavior characteristics are present during the evaluation. Pain behavior characteristics are quick actions that may be difficult to be noticed. For the physiotherapist to be successful with this technique it will take time and practice, but once the Overt Pain Behavior Guide is mastered the physiotherapist will be able recognize the patients condition sooner and better. The search of information on the Overt Pain Behavior Guide by Keefe and Block (1982) showed no statistical evidence to prove the reliability and validity of the guide in its use to identify patients exhibiting pain behavior. The study was limited to the use of abstracts from Medline and Pedro. The only available abstract was from Waddell and Richardson (1992), but the abstract for their article, Observation of Overt Pain Behavior by Physicians during routine clinical examination of patients with low back pain, failed to provide any statistical evidence about their clinical trial in the abstract. However, the study by Waddell & Richardson (1992) found that overt pain behavior was found to be related to other clinical measures of illness behavior such as pain drawing, behavioral symptoms, behavioral signs and use of walking aides. Further clinical research is needed to determine if the Overt Pain Behavior Guide can be used as a reliable and valid tool by physiotherapists in the prevention and diagnosis of chronic pain. Table 6. Summary of Overt Pain Behavior GuideCost effectiveShort, easy to remember five characteristicsSome training requiredVulnerable to observer error and bias in clinical settingsNo statistical evidence 2.4.3.2 Pain Drawing The pain drawing is a simple and effective assessment tool for the patient to express their pain and suffering to the physiotherapist. Other medical professionals who also deal with chronic pain patients may use the pain drawing. This tool allows the patient to convey their pain behavior by drawing where the pain is in their body. If it is difficult for the patient to speak or express their suffering in words, the patient can draw their pain behavior. This is particularly effective with patients who are new immigrants and/or have difficulty in speaking. The pain drawing is easy and quick to administer to patients because it has an understandable presentation that is simple to comprehend. From the available systematic reviews and random controlled trials (RCTs) that were used to research the pain drawing only the abstracts were available for analysis. According to Chan et al 1993; Ohnmeiss 2000; Rantanen 2001 the pain drawing is a stable and reliable tool for use with chronic pain patients. However, the statistical evidence provided in the available resources was not able to prove the validity, reliability, specificity and sensitivity of the pain drawing as an assessment tool for the prevention and diagnosis of chronic pain. More research needs to be done or gathered to verify if the pain drawing is a reliable assessment method. Table 7. Summary of Pain DrawingSimple, understandable presentationProvides insightful information about reactions and effects from painDescribes the painGives insight to psychological state of the patientStatistically reliable, however insufficient evidence  2.4.4 Questionnaires In order to get a hold of the patients sense of pain suffering and disabilities the therapist should arrange the examination in a way which is appropriately time consuming and provides insight into the patients condition. The patients psychological state should not be overlooked since it is expressed in the experience of their pain and disabilities. As with the clinical assessment, questionnaires such as the visual analog scale (VAS), Pain Disability Index (PDI), Multidimensional Pain Inventory (MPI) and New Zealand Guidelines to Assessinfg Psychosocial Yellow Flags possess inherent benefits and drawbacks. The New Zealand Guidelines Group outlined them as: Table 8. Advantages and Disadvantages of QuestionnairesAdvantagesDisadvantagesQuick to administerRequire time to scoreUseful for screening large numbersNeed to check for missing informationLittle skill neededUnsuitable for those with reading problemsInterpretation is usually unequivocalMay not be applicable to all member of a community (i.e. new immigrants)Can be statistically based on evidenceMay only predict one goal (i.e. Work loss)May be too sensitive to time of measurementSusceptible to confounding factors, such as social desirability or impression management such as the person telling you what they think you want to hear  2.4.4.1 Visual Analog Scale (VAS) The Visual Analog Scale (VAS) is recognized by health professionals and patients as a quick way to gain an objective measure on pain. It is a well-known pain assessment tool with widespread popularity coming from its simple straightforward nature, as well as its ability to be performing verbally. Specific to chronic pain though, statistical evidence is weaker for chronic pain patients. According to Huskisson (1987) it has shown to be very reliable (r=0.97) and valid (r=0.70). The results of the search indicate there is a need for further study in the specificity and sensitivity of the VAS. Table 8. Summary of VAS scoreWell knownSimpleMay be done verballyStatistically lower consistency with chronic pain patients 2.4.4.2 Pain Disability Index (PDI) The Pain Disability Index unlike most other assessment tools and questionnaires provides a functional insight into a patients limitations in the areas mentioned above in section 3.3.4. The seven functional areas covered in the PDI provide a broad functional spectrum of the patients capabilities. As a self-reporting index the patient is able to fill out the questionnaire on their own without any sort of influence from the physiotherapist. The PDI was designed to be used by various medical professionals and not only physiotherapists. The PDI proved to be reliable (r=0.87) by Tait et al (1990) and according to Strong, Ashton and Large (1994) was valid (r=0.76). Further research needs to be done to describe the specificity and sensitivity of the PDI. Table 10. Pain Disability IndexProvides insight regarding functional limitationsSelf-reporting indexBroad functional spectrum illustratedStatistically valid 2.4.4.3 Multidimensional Pain Index (MPI) The Multidimensional Pain Index (MPI) is a self-reporting questionnaire that shows the cognitive, affective and behavioral dimensions of the chronic pain patient. The MPI is valued for its brevity, ease of scoring, and utility in different clinical setting. The MPI is a general questionnaire that was developed for use by various medical professionals such as physiotherapists. However, the MPI consists of sixty-one questions and takes over twenty minutes to complete. An internal flaw of the MPI is that it takes a long time for chronic patients who are already anxious, not to be able to focus on the questionnaire and complete it correctly. Dysfunctional or interpersonally distressed have significant psychosocial issues, may benefit from a multi-disciplinary approach to their chronic pain treatment. It is widely suggested there are patients with chronic pain undergoing treatment at outpatient physical therapy clinics who would benefit more from a multidisciplinary approach (Hankin, 2001). More research is needed to determine if the MPI could serve to determine if a patient already receiving treatment in an outpatient physiotherapy clinic required a multidisciplinary treatment for their condition. Further research on the MPI is essential since the reviews of abstracts from Medline and Pedro revealed that there is no statistical evidence for the validity, reliability, specificity and sensitivity of the MPI. Table 11. Multidimensional Pain InventoryIllustrates cognitive, affective and behavioral dimensions of chronic painRelatively time intensive for patient completion and therapist interpretationRelevant to many fields healthcareStatistical reliability information is not yet available 2.4.4.4 New Zealand Guidelines to Assessing Yellow Flags 2.4.4.4.1 Assessing for Yellow Flags When a large patient group is to be screened quickly the usefulness of questionnaires is recommended. This allows minimizing the number of false positives, determining those patients truly at risk. A false positive is a patient who is not actually at risk of developing a chronic condition and was screened out by the test. Skilled clinicians with adequate time must perform the clinical assessment to make an accurate identification of yellow flags preceding intervention. Should skilled personnel be in short supply and/or there is a large patient group to be evaluated, the two-stage approach in figure 3. must be implemented. The questionnaire can provide further assessment. The number of false negatives needs to be minimized through the use of the questionnaire. False negatives are those patients who have risk factors, but are missed by the screening test. Clinical assessment may be supplemented with the questionnaire method if it has not already been done. Further, treatment providers familiar with the administration and interpretation of other pain-specific psychometric measures and assessment tools (pain drawing, VAS score, PDI and MDI) may choose to employ them. The key question that the physiotherapist should keep in mind through out the clinical assessments is: What can be done to help this person experience less distress and disability? The list of yellow flags provided by the New Zealand Guidelines Group is not exhaustive and the order of significance will vary from patient to patient. Some listed yellow flags may appear to be mutually exclusive, while in fact they are not. For example, partners can alternate from being socially punitive (ignoring the problem or expressing frustration about it) to being over-protective in a well-intentioned way (and inadvertently encouraging extended rest and withdrawal from activity, or excessive treatment seeking). In other words both factors may be present. The presentation of the list is in alphabetical order of categories (Attitudes and Beliefs about back pain, Behaviors, Compensation Issues, Diagnosis and Treatment, Emotions, Family and Work) because it is difficult to rank their importance uncategorically. Though within each category the factors are listed with the most important factor first. Table 12. Psychosocial Yellow flagsProvides a summary of risk factors for long-term disabilityCan be applied to a large patient populationInterpretation is time intensiveDoes not emphasize one social category over another 2.4.4.4.2 Consequences of Missing Yellow Flags Not identifying the At Risk patients can lead to inadvertently reinforcing disabling factors. Failure to note that specific patients strongly believe that movement will be harmful may result in them experiencing the negative effects of extended inactivity. This includes social, professional and recreational withdrawal. Bear in mind the physiological consequences (muscle wasting) that are results of cognitive and behavioral factors. The number of earlier treatments and the problems length can be indicating factors of risk; most people should be identified upon the second episode of treatment. Chronicity can develop when yellow flags are consistently overlooked. There are severe adverse consequences if yellow flags are not recognized. 2.4.4.4.3 Over-identification of Yellow flags Over-identification of yellow flags can lead to the wasteful usage of resources. However, this is outweighed by the large benefit of helping to prevent even one patient developing a long-term chronic pain. It is reasonable to question whether identification of yellow flags, therefore applying suitable cognitive and behavioral management, will produce adverse effects. Certainly if the presence of psychosocial risk factors is mistaken to mean that the problem should be translated from a physical to a psychological one. The danger would be the patient losing confidence in themselves and their treatment provider. There are unlikely to be adverse consequences from the over-identification of yellow flags. The presence of risk factors should alert the treatment provider to the possibility of long-term problems and the need to prevent their development. Specialized psychological referrals should only be required for those with psychopathology or for those who fail to respond to appropriate management. Table 13. Over- and under- identifying of yellow flagsUnder-identification of at-risk patients can reinforce disabling factors, having dire consequences to the patientOver-identification of risk factors may lead to wasteful us of resources in the short term.The short-term costs resulting from over-identification are negligible compared to the long-term treatment stemming from under-identification The New Zealand Guidelines to Assessing Yellow Flags focuses on the prevention of chronic pain and disability. The target of identifying those patients at risk through appropriate early management is needed in prevention. The yellow flags used in the guidelines are psychosocial factors that are likely to increase the risk of a patient with an acute condition in becoming a chronic pain patient. These guidelines are the foundation for the prevention and early diagnosis of chronic pain. However, more research through random clinical trials that use the New Zealand Guidelines to Assessing Yellow Flags are needed to provide statistical evidence to evaluate the validity, reliability, sensitivity and specificity of the guidelines. 2.5 Conclusion This study showed a small collection of the many assessment tools available to physiotherapists in the prevention and diagnosis of chronic pain. In the search of the available sources there was little emphasis found on the prevention of chronic pain. The optimum assessment tool is the awareness and selection of tools specific to the individual patient. The six assessment tools, questionnaires and guidelines: Overt Pain Behavior, Pain Drawing, Visual Analog Scale (VAS), Pain Disability Index (PDI), Multidimensional Pain Inventory (MPI), New Zealand Guidelines to Assessing Yellow Flags are general assessment methods that were designed for all medical professionals dealing with chronic pain patients. These assessment methods were not specifically designed for physiotherapy but they do lay the foundation for a promising set of tools to be used in the future for physiotherapeutic use in the prevention and diagnosis of chronic pain. Further statistical research and evidence is needed to establish the reliability and validity of these six assessment methods and to justify their use in physiotherapy. Chapter 3.0 Physiotherapy for Chronic Pain Introduction The treatment of chronic pain patients with physiotherapy includes a wide variety of subjects. Some of these subjects may be made use of by other professions as well as by physiotherapy because the treatment is envisioned as multidisciplinary. However, the focus here is on physiotherapy and the interventions appropriate for use by this profession with respect to chronic pain patients. The type of physiotherapy applied is a concern. The shift in practice at this time is to functional ability. The concept of functional ability is related to contemporary physiotherapy. The other concept, rest for chronic pain, is related to conventional physiotherapy. Rehabilitation, Activity, Function restoration, Psychological status and Planning for relapses are all subjects addressed by physiotherapy when treating patients with chronic pain. In this chapter, there will be two types of treatments presented. General treatments, that can be employed by related professions such as psychology, and Specific treatments, that are intended for physiotherapy. The previous section on assessment tools serves to provide the therapist with information that will aid in directing the efforts during treatment. 3.0.1 Objectives To perform a systematic review based on the findings of research from modern studies and literature. This review will compare different physiotherapy treatments employed in individual countries. Ultimately, summarizing an optimal intervention suggestion of chronic pain patients in physiotherapy. 3.1 Data Collection and Analysis The four reviewers utilizing the pre-established criteria reviewed the results of the search. The treatments were then identified for utility and significance on the basis of clinical significance to the treatment of chronic pain, applicability to physiotherapy, clarity and contemporary relevance. A secondary search for the effectiveness of prescribed therapies was done. The references for the treatment of chronic pain to be used for the search were outlined in advance as: The textbook of Pain by Melzack and Wall The Back Pain Revolution by Waddle Tabers Medical Dictionary International pain organizations American Pain Association Canadian Pain Society Australian Pain Organization International Association for the Study of Pain Table 1. Terms searched Chronic PainPhysiotherapy for Chronic PainPhysiotherapy Treatment parameters for (and) Chronic painRehabilitation Strategy for (and) Chronic painRelapse Management for (and) Chronic pain  Pertinent treatments were searched for and discovered using the texts, journals and medical dictionaries. In addition, Website queries were done generally using Google and specifically to organizations web sites. Searches for evidence were performed on PEDro The Physiotherapy Evidence Database. Systematic reviews and studies were searched for via MEDLINE, CINAHL,COCHRANE and bibliographies of identified studies. Lastly, known practitioners (example: Bernadette Smetsers, Physiotherapeut and Frank Verhulst, Drs of Psychology. Both are Instructors of higher education at Fontys Hogeschool at Enidhoven, The Netherlands) provided expert opinions. 3.2 Selection Criteria Reviews and studies about physiotherapy treatments were included which described guidelines and treatment parameters for chronic pain. The primary focus was on functional rehabilitation. Material was gathered with respect to the relevance during therapy to the patient and the therapist. The selection criteria included whether the article provided a broad based substrate from which to explore the question of how to treat chronic pain patients. Articles or material must adhere to the scientific standards for research and publication. The articles of research used will be systematic reviews and/or random controlled clinical trials (RCTs). Provides international perspective on the prevention and diagnosis of chronic pain patients in physiotherapy. Sixty-nine guideline examples were determined to be of appropriate quality were retained. Forty-three were rejected from consideration and discarded. Table 2. Selection CriteriaAreas of SearchSubject MatterSelected material1. Systematic Reviews1. Physiotherapy specific, treatment options for chronic pain patients.1. Was relevant to patient and therapist.2. Random Controlled Trials (RCTs)2. Provided a broad base to be used to explore the treatment of chronic pain.3. Published Studies Table 3. Search Summary for Physiotherapy for chronic painTerms Searched References UsedConsideration Criteria1. Chronic Pain1. The textbook of Pain by Melzack and Wall (1998)1. Clinical significance to the treatment of chronic pain2. Physiotherapy for Chronic Pain2. The Back Pain Revolution by Waddle2. Applicability to physiotherapy3. Physiotherapy Treatment parameters for (and) Chronic pain3. Tabers Medical Dictionary (1999) 3. Clarity4. Rehabilitation Strategy for (and) Chronic pain4. International pain organizations websites: -American Pain Association -Canadian Pain Society -Australian Pain Organization -International Association for the Study of Pain4. Contemporary relevance5. Relapse Management for (and) Chronic pain 3.3 Results The information stated here are the direct findings of research for treatment guideline examples. There were one hundred and twelve treatment guidelines found during the search. Sixty-nine guideline examples were determined to be of appropriate quality and therefore could be included, but forty-three were rejected from consideration (See section 4.1.1, for the selection criteria employed). The expert opinions garnered were among the material judged to be of a credible, appropriate and highly useful nature. The located RCTs, Systematic reviews as well as expert opinions supported individual treatment planning, regular involvement in exercise programs, activity over rest, and implementation of the New Zeeland guidelines. Functional restoration, psychological approaches and relapse planning were also among the concepts supported. NOTE: The order for the subsequent sections was chosen to provide for a logical order which progresses from global to specific therapy applications. The sections are ended with contingency plans and support for the discussed results. 3.3.1 Rehabilitation Strategy A treatment plan is a practical and systematic declaration. It is an aid for making decisions, and an example of specific clinical interventions. The plan used to improve the fitness level and physical function of the patient must be unique, and as individual as the patient. As we help our patients to regain control of their lives, it is necessary to remember that our purpose is to guide them into a gradually increasing amount of activity. In doing so, we must incorporate the participation of the patient and activity-oriented goal setting into the treatment plan. It is fortunate that many of the problems related to deconditioning are reversible through exercise. In order to reverse the problems that a decreased state of physical fitness creates, the patient must participate in an exercise program. Supervised programs have a very good track record for improving the fitness of the people involved. The type of exercise program is not as important as regular involvement in an appropriately supervised program. The exercise regimes should gradually increase in duration and intensity, starting from below the patients current level of capability. Compliance is greatest with exercises that can be transferred from the clinical setting into the patients normal practice outside the clinic. Table 4. Rehabilitation Focus PointsTreatment plans must be individual.Exercise programs reverse deconditioning problems.Exercise intensity level & duration should increase on the basis of time, not symptoms.Regular involvement in an exercise program is necessary for best results. 3.3.1.1 Pain rehabilitation Pain rehabilitation is an integrated process that addresses medical management and treats the physical and biopsychosocial aspects of persons with acute and chronic pain. Pain rehabilitation uses conventional methods, such as Heat and Cold therapy, electric, traction and manual therapies as well. At this time, there is uncertainty about how to maintain the gains achieved through treatment. The cost of an in-patient program according to the Wessex Institute for Health Research and Development in the U.K. was judged to be approximately 3,750 compared with 1,900 for an outpatient program, in the United Kingdom. The benefits of treatment have been estimated at 0.1 quality adjusted life years (QALYs) per year of treatment, assuming all patients benefit. This gives a cost per QALY gained of between 1,316 and 17,420 based on one year or ten-year duration of benefit, respectively. The cost per each year the quality of life is improved was estimated to be around 2,500. The authors of this study recommend the results be cautiously interpreted. The research on this subject is being completed very quickly and new information is regularly being presented. The focus of this paper is chronic pain and not acute pain. In view of the fact that the methods traditionally used are not supported by evidence to have a long-term clinical affect on chronic pain, the physical rehabilitation techniques normally used in pain management, it was decided, would not be presented. Table 5. Pain Rehabilitation Focus PointsPain rehabilitation makes use of conventional methods.The cost per year for each year of quality of life improvement is ~ 2,500 Research continues on the question of how to maintain advances made during therapy. 3.3.1.2 Rest or stay active? What can clinicians advise patients with chronic pain to do? The advice given is pivotal. It has been stated previously that clinicians can influence the patients condition through, advice and actions. If the patient is lead to focus on their pain while discussing their problem, they will continue to fixate on their pain and their disability level will be adversely affected. Conversely, if the therapist helps the patient focus on his coping method and directs the patients attention to what is functionally possible, the areas of disability level and subjective pain report (among others) are positively impacted. Therefore, it matters what patients are told and how they are directed. Chronic pain patients function at a level near their maximum due to their decreased fitness level; but exercise programs have the capability to undo the damage done to the body as a result of inactivity. That being said, the next natural step would be to advise the chronic patient to become active again through exercise. Sustaining activity is also in the best interest of the patient, which would make resting to recuperate after a recurrence of pain symptoms inadvisable. The following section will explore the question of rest or activity further. At least through the early 1990s, rest was the most common treatment advised by physicians apart from analgesics. Many physicians advised the use of medications for a longer period. For example, the table below illustrates the percentage of instances a patient was advised to take medications once and multiple times, when presenting for treatment due to pain. Taking medication during the initial instance of pain is very different from being advised to take medications three times a day for three weeks. Table 6. Clinical Treatment percentagesTreatment AdvisedSingle treatmentMultiple treatmentsTotalsAnalgesics18%69%87%Bed rest21%27%48%Physical Therapy10%14%24% The concept of bed rest for illness came about from the inability of people who were seriously ill to continue with their daily lives in the face of their condition. They frequently ended up in bed. Because of this, the assumption was made that bed rest was the appropriate treatment for illness. As late as 1995, British textbooks used for the education of physicians still advocated rest as a treatment for nonspecific low back pain (Waddell, 1998). Many patients are miss led by the advice of doctors who tell them that they should reduce their activity or that they should spend time in bed, even though doing so has been found to be itatrogenic for patients. Iatrogenesis is defined to be any adverse physical or mental condition induced in a patient through the effects of a treatment by a physician or surgeon. For example, in an elderly person, the consequences of a fall can lead to the use of restraints and/or bed rest, which can cause thrombophlebitis. The concept of bed rest for illness was not immediately accepted. One of the earliest English orthopedic texts on back pain was a lecture by Johnson (1881), who, in his lecture, advised against bed rest, because he believed bed rest to be the cause of back pain Rest had its opponents. Recumbency admits failure and should be the doctors last thought, not his first (Cyriax 1969). Their voices were not headed because the principle of therapeutic rest had become the traditional medical treatment for back pain. This concept of bed rest as the standard treatment for pain endures in many places to this day. Presently, the errors of this philosophy have been illuminated and a change is taking place. The traditional concept of bed rest for pain is giving way to graded activity as a much more suitable treatment for chronic pain. Advice from doctors varied according to their educational background. Patients also vary. The well-educated patients are more likely to stays active; the less well educated are more likely to heed advice to rest (Korff et al, 1994). Patients with low back pain make up the majority of chronic pain patients and pain is the most common reason for consulting medical care. Studies have been done on the question of rest or activity. There is substantial evidence that supports activity over rest. But there are still opponents who believe that rest is appropriate, based on tests that conclude the benefit of activity is not as great as proposed, or that bed rest is only mildly harmful. Table 7. Rest or Activity Focus PointsBed rest for illness is counter productiveThe concept of graded activity is becoming the new standard treatment for chronic pain. Table 8. Evidence for rest or activityAuthorTherapy usedConclusionNotesHagen KB, Hilde G, Jamtvedt G, Winem M, 2002Bed rest vs. staying activeNo important difference in exercise vs. 2 or 3 days rest.Level IIMalmivaara et al, 1995Ordinary activityImproved recovery rate, Decreased pain, disability and time off work.Level II 3.3.1.3 Increasing Activity Levels Activity levels should increase by planned, fixed increments over time. The starting point may be set with respect to the current symptoms of the patient. The start of activities should also begin below the level the patient is currently capable of as a boost to their morale and motivation. Achieving a goal they had previously failed at would be a very good start for a chronic pain patient. Thereafter, there should be regular increases in the level, duration and intensity of the activities for which the patient is responsible. The subsequent increases should be based on time and not symptoms. The pace of the increases should be gradual. Attempting too much, or proceeding too quickly could incite an exacerbation of pain in the patient and damage their already questionable motivation. The rate of the increases will be dependent upon the individual patient. The therapist will have to exercise good judgment and determine what the patient can realistically accomplish in a reasonable period of time. A very helpful point to get across to the patient is that gradually increasing the activity level and remaining active, decreases pain. Passive modalities will only lead to dependence and continued pain experiences. Table 9. Increasing Activity Level Focus PointsStart below the current capacity level of the patient.Regularly increase the activity level, duration and intensity.Gradually increased activity alleviates pain.  3.3.1.4 Active Rehabilitation Active rehabilitation is different from exercise, as it is commonly understood. The intention is to increase the patients activity level and restore normal function. The focus of active rehabilitation is on functional activities, like working around your home. Active rehabilitation may be explained as the difference between doing an isolated exercise for a single muscle group, and the intervention by a therapist who makes use of the information from the assessment and other sources, to improve the way a patient walks According to Waddell (1998), to be effective, physical therapists should apply the same rehabilitation principles to back pain that they use in every other musculoskeletal condition. Table 10. Active Rehabilitation Focus PointsThe goal of active rehabilitation is to increase activity level & restore normal function.The focus is on functional activity, like the activities of daily life. 3.3.1.5 Changing Beliefs Rehabilitation is generally thought of as purely having an influence on the physical and physiologic status of a patient via reactivation. Changing what a patient thinks about his/her pain and how they cope with it may be as important a task as getting the patient moving again. This point was made in the Revolution of Back Pain as well as in the New Zealand guideline to assessing psychosocial yellow flags in low back pain. To examine the associations between a change in thought patterns and coping and multidisciplinary pain treatment outcomes, 141 patients with chronic pain participated in a study. The spouses of the patients rated the physical functioning at pre-treatment, post treatment, and at the 6- and 12-month follow-ups. The methods used to adjust beliefs were not expressed. What was learned was consistent with the hypothesis, that favorable results of pain treatments were associated with the adjustment of the thought patterns and coping of patients. Jensen MP, Turner JA, Romano JM, (2001). It is very important to alter how a patient thinks of his /her pain in order to have favorable affects with treatment. How a patient thinks about their pain will have an influence on how they move, exercise and conduct activities of daily life. If the patient thinks that pain is a signal that damage is occurring then they will not think it suitable to participate in an exercise program. Alterations in beliefs can influence the disability level as well as the reported pain experience of the patient. Table 11. Changing Beliefs Focus PointsThoughts influence conduct.Modifying a patients thought patterns can improve the impact of therapy. Table 12. Evidence for changing beliefsAuthorsTherapy usedConclusionNotesJensen MP, Turner JA, Romano JM, 2001Changing Beliefs and Coping processesChanging what a patient thinks of their pain facilitates a better treatment outcomeLevel I 3.3.1.6 New Zealand Guidelines To date there is a great deal of evidence about the effectiveness of various specific treatments. Unfortunately, little has been produced regarding general treatment parameters and guidelines for intervening with chronic pain. While the importance of functionally directed therapy has been established, the integration of the biopsychosocial factors is still needed. The New Zealand Guidelines Group (NZGG) published a detailed and comprehensive guideline. Their recommendations can be grouped into four categories: functional maintenance, counseling recommendations, scheduling hints and suggestions for involving multidisciplinary professionals. 3.3.1.6.1 Functional Maintenance Emphasizing the patient's maintenance of their functional activities, to a reduced degree, as long as possible is recommended. For both professional and recreational activities, the more contact the patient can maintain with their colleagues increases the likelihood of a successful return. As time away from the job increases, the probability of returning decreases. Maintaining relations with employers, co-workers and colleagues decreases the stress of returning and provides valuable social support to the patient. Should the patient be suffering in their condition for more than six weeks, a functionally appropriate redirection should be made. Indicating to the patient that a return to previous levels of activity may not be achievable is appropriate. This may result in a change of hobbies or a vocational modification. A new position with the same employer might be an acceptable recommendation. The patient should also have it explained that pain can be controlled in order to maintain normal functions. This does not mean pain will cease entirely, merely that it can be controlled. Realization of this is important in the patients coping style and pain behavior. Table 13. Summary of Functional MaintenanceMaintain reduced functional activities as long as possible.At six weeks, suggest a functional redirection Educate patient about controlling pain to maintain normal function 3.3.1.6.2 Counseling Recommendations Interaction and coaching of the patient is where the psychosocial considerations have their greatest implications. When communicating with the patient, concede hitches with activities of daily living. Though in doing so, do not make the assumption that these indicate cessation of all activity or any work must be made. Reiteration of the activity level adjustments will reinforce this. If the patient expresses hope for complete recovery or a technological fix before returning to work, a more levelheaded expectation should be called for. Uncorrected, these beliefs will precipitate prolonged heightened focus on symptoms. Further, these expectations will justify an unduly long time away from work. Cognitive adjustments for the patient are critical in developing realistic, positive, expectations for treatment. Emphasizing the prospects of returning to work and social activities. This should not be construed to mean encouraging an impractical outcome. If the problem lasts beyond a normal time frame for acute pain (see chapter 2), be prepared to warn to patient with respect to which outcomes may be realistic and which may be unattainable. Improving the patients ability to manage and be accountable for the outcome of their condition. This includes emphasizing an internal locus of control over their return to functional activities. Developing self-efficacy is dependent upon the feedback and incentives from the physiotherapist and others in their social network. (Note: feedback is not likely to affect the recovery based upon the development of a new skill, as in posture.) Pragmatically, recognizing and maintaining awareness of progress, no matter how small, is important in improving the patients mindset. Focusing interview questions on the functional limitations rather than descriptions of the pain will shift the focus from the symptoms to the ability level. Asking questions such as What are you able to do? instead of How much pain do you have? averts the focus of attention from the pain. In addition, phrasing the questions in positive manner will provide important emphasis on the ability rather than the disability. Reports of symptoms and emotional distress need to be seen exclusively. It has been shown that emotionally distressed patients will seek prolonged medical intervention. Emotional distress needs to be addressed if the cessation of symptoms is to occur. Table 14. Summary of Counseling recommendationsConcede difficulties in Activities of Daily Living, without assuming they indicate complete cessation of activities.Develop realistic outcomes for treatment and returning to previous levels of activityEmphasize the self-efficacy of the patientView emotional distress and symptoms exclusivelyMaintain interest in improvementsPhrase questions to emphasize function rather than symptoms and ability rather than disability 3.3.1.6.3 Involving multidisciplinary professionals Encourage further relations between patient, employer, and compensation system and health professionals. This may include involved social workers, insurance (or workers compensation) agents and work supervisors. Their collaboration is even more important when there are numerous complexities to returning to work. Seeking a second opinion is an option to consider when it does not involve an inhibitive delay. This second opinion may elucidate that a second opinion is not necessary. As complexities arise be prepared to admit your uncertainty rather than provide reasons based upon assumption. The physiotherapist must also encourage cooperation amongst the patient, employer, insurance provider and other health professional. Unintentionally dividing the healthcare team between them and us can do irreparable harm to the relations of all parties involved. Table 15. Summary of Involving Multidisciplinary ProfessionalsEncourage continued relations with workplace, insurance organization and healthcare providersSeek a timely second opinion when complexities arise.Admit uncertainties as opposed to speculating for reasons.Reinforce a unified healthcare team. 3.3.1.6.4 Scheduling hints The NZGG emphasizes the importance of the physiotherapist being pro-active in the scheduling of regular reassessments of treatment. Clear and accurate reporting of upcoming appointments and meetings with other healthcare providers ensures adequate communication can be prepared. Delays in this communication will critically hinder the rehabilitation of the patient. Table 16. Summary of Scheduling Hints The therapist is responsible for regular reassessment of treatmentClear and accurate reporting of the patients appointments ensures the timely communicationTimely communication with allied healthcare providers is essential 3.3.2 Conventional Physiotherapy Introduction The following section of conventional physiotherapy is distinguished from contemporary therapies such as functional restoration by its method of treatment. Conventional, or traditional physiotherapy as it is better known, uses methods such as Exercise, Manual therapy or manipulation, Hydrotherapy, Electrical therapy like TENS and other methods like Traction, Massage, Thermo therapy and Ultrasound. Among these methods are those, which are in accordance with the current shift in physiotherapy today, exercise therapy for example. Other methods among those categorized as conventional are passive such as electrical therapy. It must be noted however that there are even methods included that are a conjoining of both contemporary and conventional. An example of this is hydrotherapy, as it incorporates both warmth and exercise. This section will cover the afore mentioned treatment methods and offer explanation of their respective utlity in practice. 3.3.2.1 Exercise Therapy Exercise has been shown to produce better rehabilitation results than the other interventions available in the treatment of chronic pain. Reviews based on trials published up to 1992 conclude that the efficacy of exercise therapy in patients with chronic pain is questionable (Faas, Battie, Malmivaara, 1996). There is much evidence documenting the efficacy of exercise in the conservative management of chronic pain, but many questions remain regarding its exact prescription and method of application. The most successful method must be identified to enable the enhancement of future rehabilitation programs to target the specific needs of the chronic pain patient and the budgets of the healthcare providers. Different training models are effective for the treatment of chronic pain, but no consensus exists. Most of the research studies and reviews for chronic pain to date have focused on chronic low back pain. To judge the strength of the evidence on which recommendations are based The Australian National Health and Medical Research Council (NHMRC) has issued guidelines for analysis. They distinguish between two levels of evidence; Level I and Level II. Level I evidence represents the desired standard on which to base clinical decision-making. This evidence is obtained from systematic reviews of relevant randomized trials (with meta-analysis where possible).' This level of evidence is therefore the strongest when considering treatment efficacy. Level II evidence is 'obtained from one or more, well designed randomized controlled trial (RCT).' Table 17. Summary of Australian classification of EvidenceLevel I evidence = based upon systematic reviews Level II evidence = obtained from one or more randomized clinical trial 3.3.2.1.1 Benefits of General Exercise The benefits of exercise programs for the treatment of chronic pain have been studied and proven at length (van Tulder et al, 1996; Waddell 1998; Faas, Battie, Malmivaara, 1996). Though the causality of improvement from exercise may be disputed. Both Level I and II evidence make a convincing case for the inclusion of exercise in the treatment of chronic pain. Structured exercise programs have been shown to be effective in both the prevention and treatment of low back pain. (Maher, Latimer, Refshauge, 1999). The type of exercise program is not a determining factor in the rehabilitation of patients. When an intensive exercise program was compared to a muscle training and coordination program, no distinction was evident in the improvement of pain scores, disability indexes and spinal mobility. (Johannsen et al, 1995) 3.3.2.1.2 Cost Effectiveness Therapeutic exercise programs have been shown to be cost effective in comparison to non-intervention (Gundewall et al 1993). In the workplace, exercise groups with chronic low back had a lower absenteeism. When compared to reductions in wages, the cost of the exercise programs was far less (Mitchell et al, 1990). Providing further evidence to the cost effectiveness, exercise programs reduced absenteeism and increased return rates to work. (Kellet et al, 1991; Gundewall et al, 1993; Mitchell et al, 1990). 3.3.2.1.3 Functional Exercise Including functional exercise has also been found to increase the success rate of rehabilitation. (Australian Physiotherapy Association, 1999) The comparative study between functional exercise and general exercise programs showed increased results in rehabilitation from a comprehensive program including intensive training, ergonomic training and behavioral support. These findings support the previously sited studies on the importance of a biopsychosocial approach. Four multidisciplinary functional restoration programs concluded that the treatment was effective, particularly if it excluded passive therapies (Australian Physiotherapy Association, 1999) Evidence supports the current trend towards a more active approach to chronic pain treatment. Exercise has been able show a significant reduction in pain intensity, frequency and functional disability levels. More research on exercises with a more specific and graded activity program and on different types of exercises for patients with chronic pain is necessary. Inadequate reports of descriptive statistics and lack of distinction across the available studies make a statistical meta-analysis difficult. No firm conclusions concerning efficacy of exercise in the treatment of chronic pain can be drawn from the existing RCTs and reviews. There is a need for more research studies with high internal validity, and exercise procedures based on established theoretical principles concerning type and dose of exercises. Table 18. Level I Evidence For Exercise TherapyAuthorsTherapy usedOutcomesNotesVan Tulder et al, 1996; Waddell 1998; Faas 1996General exercise programEffective in treating chronic low back pain as well as chronic painLevel IMaher C, Latimer J, Refshauge K, 1999Structured exercise programsStrong evidence supporting use of exercise for treating chronic low back painLevel IVan Tulder et al, 2000Exercises may be helpful in returning patients to normal daily activitiesLevel IHilde G, Bo K 1998Exercise programs for chronic low back painMore trials with high internal validity, exercise protocols based on established theoretical principles concerning type and dose of exercises are neededLevel IFaas, Battie, Malmivaara, 1996General exercise programsMore research on graded activity program, and types of exercising for chronic back pain is necessaryLevel I Table 19. Level II Evidence for Exercise Therapy AuthorTherapy usedResults/ ConclusionsNotesFrost et al, 1995; Frost et al, 1998Exercise and EducationImproved disability, pain, walking distanceLevel IIMaher et al, 1998Physical conditioningImproved disability, painLevel IIKellet et al, 1991; Gundewall et al, 1993Exercise programsReduced absenteeism, hastened return to work over control groupLevel IIGundewall et al, 1993; Mitchell et al, 1990Physiotherapy intervention with chronic low back painCost-effectiveLevel IIGundewall et al, 1993; Mitchell et al 1990Level IIMitchell et al, 1990Exercise programLess absenteeism. Cost effective to decreased wages.Level IIFrost et al. 1998 Level IIManniche et al, 1988Intensive exercise compared with passive therapyResults favored intensive exerciseIntensive exercise program was cost effective in groups.Kankaanpaa et al, 1999Active rehab compared with passive Active progressive treatment was more successful in reducing pain, decreasing disability, improving lumbar endurance.Level IIMannion et al, 1999Active physiotherapy, muscle reconditioning on training devices, low-impact aerobicsLumbar mobility improved more with aerobics than PT or training devicesAerobics were more cost-effectiveJohannsen et al, 1995Endurance training vs. Coordination Both groups improved in pain, disability and spinal mobility.Level IIBendix et al, 2000Intensive physical training, ergonomic training, and behavioral support vs. outpatient intensive physical trainingFunctional rehabilitation had favorable assessment resultsComparative results suggested compensation incentive had an impact in results 3.3.2.2 Manual Therapy Most reviewers conclude that the strongest evidence for manipulation is in acute low back pain (Waddell 1998). Some systematic reviews have failed to find sufficient evidence to support or counter the use of manual therapy in the treatment of chronic low back pain (Australian Physiotherapy Association, 1999). However, van Tulder et al (1996) also found nine RCTs of manipulation for chronic low back pain. They concluded that there is strong evidence that manipulation is more effective than placebo, and that there is moderate evidence that it is more effective than most other treatments to which it has been compared. Furthermore, there is moderate evidence that manipulation is more effective for chronic low back pain than usual care by the general practitioner, bed rest, analgesics and massage (van Tulder et al, 1997). In comparison to exercise therapy, manual therapy follows as a secondary role in treatment (Australian Physiotherapy Association, 1999). Table 20. Evidence for Manual TherapyAuthorsTherapy UsedConclusionsNotesAustralian Physiotherapy Association, 1999Manual TherapyInsufficient evidence to support or refute its use. Secondary to exercise therapy in treatment.Level I Van Tulder et al, 1996 Manual TherapyMore effective than placeboLevel I Van Tulder et al, 1997Manual TherapyMore effective than care by general practitioner, bed rest, analgesics & massage.Level I  3.3.2.3 Hydrotherapy Hydrotherapy is believed to combine the elements of warm water immersion and exercise to produce therapeutic effects in the treatment of chronic pain (Hall et al, 1996; Constant et al, 1998). In a study by Sjorgen et al (1997), sixty subjects with chronic low back pain were sequentially allocated to either hydrotherapy treatment or land treatment groups in order of presentation. The results indicated that both groups improved significantly in functional ability and in decreasing pain levels. Overall, there was no significant difference found between the two types of treatment. The results should be viewed as encouraging for the advocates of both hydrotherapy and land-based exercise as a treatment for chronic low back pain. In a RCT by Guillemin et al (1994) it was concluded that after nine months of treatment hydrotherapy had a positive short-term and a moderate long-term effectiveness on chronic by showing a continued reduction in pain and drug consumption, and improvement in spinal mobility. More research needs to be done on hydrotherapy to be able to show a significant reduction in pain intensity, frequency and functional disability levels. A more specific activity program with parameters needs to be developed. No firm conclusions concerning efficacy of hydrotherapy can be given at this time. Table 21. Evidence for HydrotherapyAuthorsTherapy UsedConclusionNotesHall et al, 1996; Constant et al, 1998HydrotherapyProduces therapeutic effects.Level II Sjorgen et al, 1997HydrotherapyDecrease in pain levels and increase in functional ability.Level II Compared to exercise therapy on land.Guillemin et al, 1994HydrotherapyReduction in pain, drug consumption, and improvement in mobility.Level II  3.3.2.4 Electrotherapy Transcutaneous electrical nerve stimulation (TENS) was introduced more than 30 years ago as an alternative therapy to pharmacological treatments for chronic pain. However, despite its widespread use, the effectiveness of TENS is still controversial in the treatment of chronic pain (Milne et al, 2001; Carroll et al, 2001). There is no evidence that TENS has any long-term effect in the treatment of chronic pain (Marchand et al, 1993) There is no evidence that TENS has any long-term effect in the treatment of chronic pain In a systematic review by Milne et al (2001), five trials were included, with 170 subjects randomized to the placebo group receiving sham-TENS and 251 subjects receiving active TENS (153 for conventional mode, 98 for acupuncture-like TENS). There were no statistically significant differences between the active TENS group when compared to the placebo TENS group in any of the results. The findings of the meta-analysis by Milne et al (2001) present no evidence to support the use of TENS in the treatment of chronic low back pain. Further research is needed on how TENS effectiveness is affected by four important factors: type of applications, site of application, and treatment duration of TENS, optimal frequencies and intensities. In a systematic review of 19 RCTs by Carroll et al (2001) which evaluated the use of TENS in the treatment of chronic pain. The results of the review proved to inconclusive; the published trials did not provide information on the stimulation parameters, which are most likely to provide optimum pain relief, nor did they answer questions about long-term effectiveness. Carroll et al (2001) recommended that large multi-center randomized controlled trials of TENS in chronic pain are essential for further investigation. From the Level I and Level II research that has been conducted on the treatment of chronic pain with TENS, it seems that TENS should not be included in the treatment of chronic pain. 3.3.2.5 Traction, Massage and Modalities (Heat, Cold & Ultrasound) Therapies such as traction, massage and modalities have insufficient evidence to justify their use as a choice of treatment in the management of chronic pain (Australian Physiotherapy Association, 1999). In a systematic review by van Tulder et al (2000) there was strong evidence that traction was not effective in chronic low back pain treatment. Table 22. Evidence for conventional physiotherapyAuthorsTherapy UsedConclusionNotesMilne et al, 2001; Carroll et al, 2001TENSDoes not support its use or effectiveness.Level I Marchand et al, 1993TENSNo evidence for long-term effect.Level II Australian Physiotherapy Association, 1999Traction, Massage & Modalities (Heat, Cold, Ultrasound)Insufficient evidence to justify their use.Level I and Level IIVan Tulder et al, 2000TractionStrongly not effective.Level I 3.3.3 Functional Restoration Functional Restoration has the purpose of restoring function, with a focus on promoting and taking full advantage of functional abilities event though the pain is still present (Teasell & Harth 1996). Patients accepted into a functional restoration program are chronic pain sufferers. Characteristically, they will have endured sustained pain above normal levels, so it is realistic that a respite from their pain will be a paramount issue for them. Functional improvements lead to an improvement of the subjective account of pain. Patients are educated and persuaded to diminish their usage of health care services. These programs are usually full-time for three or four weeks. The program, based on sports medicine principals, is intensive and demanding. In this approach, there are no passive modalities as this approach is opposed to the use of passive methods. Progress is measured by the amount of current functional ability contrasted against the baseline. Getting patients back on the job was their focus and the outcome measurement. This approach was developed in response to the discontentment with traditional methods of pain management, which were viewed as merely pain pacification. The functional restoration approach uses a machine called the ISO-Machine. It measures dynamic trunk function, illustrating the importance of preventing deconditioning. This report is based on the theme of activating our patients and keeping them active. It is acknowledged that the basis of the functional restoration approach is the iso-maschine but what will be offered here for consideration is a method of treatment using the principals of functional restoration, without the use of the machine. A trademark of functional restoration is the use of impartial measures of function. Range of motion (R.O.M), Static strength, dynamic strength, endurance, aerobic capacity and tasks of daily life are measured to assess progress. The measurement of these areas gives information on the status of the disability level of the patient. It is our assertion that these areas can be measured, monitored and assessed without the use of the iso-machine. To begin, a measurement of range of motion (R.O.M.), static and dynamic strength, endurance and aerobic capacity can be taken, and used as a baseline from which to measure progress. The patient should be taught pelvic area awareness and trunk stability exercises. Thereafter, the deficiencies found during the baseline measurements can be addressed and trained. Stabilization exercises can be given. Possible examples could be: Anterior and posterior pelvic tilt/clock Supine position, neutral pelvic position, and alternating bent leg raises Pointer exercise Ball exercises At a higher level of intensity, static and dynamic strengthening can begin with a focus in the abdominal region. Static and dynamic crunches can be used along with intermediate ball exercises. Aerobic condition can also begin, starting with walking on the treadmill. All exercises are to be done with a focus on maintaining the neutral pelvic posture. The level, intensity and duration of these exercises should also be increased over time. Periodic checks can be made to assess functional ability. One method may be to simulate various activities of daily life and judge the patients ability to perform the tasks. What has been presented is an example of an appropriate functional restoration program without the use of an iso-machine. The measurement of the areas of focus provides the therapist with information to compare against the baseline values taken. This enables the therapist to assess the amount of progress made. The progress made will be directly related to the disability, and functional levels of the patient. Improvements in these areas will lead to less pain for the patient. Although the iso-machines offer an objective product and reliable measurements that can monitor progress and provide valuable feedback to rehabilitation, they have many disadvantages. They actually measure performance and not capacity for performance or strength. There is very little scientific evidence at the present time to support the claims of their advantages over other types of therapy. There is also no available, scientific evidence that the iso-machine can assess effort, (Newton & Waddell 1993) or malingering, (Newton et al 1993). Since the beginnings of the functional restoration approach began in 1985, there has been ongoing research into the claims, successes and outcome measures of this method. In 1994, the benchmark outcome measure of this method, returning patients to work, was tested by Cutler et al., (1994). The conclusion was that the method did, in fact, have a favorable influence on the rate patients returned to the job. Since this time, there has been no lack of study. Another study in Finland conducted a 3-week study using full-time in-patients aged 30-47 with low back pain for more than six months. Included were intensive fitness, muscle strengthening, an endurance program and intensive psychosocial training. There were no passive modalities or vocational rehabilitation. The participants in this program were compared to patients who only received physical therapy. At three months, the functional restoration group had improved R.O.M., strength and endurance compared with the control group. However, by the 12 month follow up there were no disparities between the two groups. The lack of a clear difference fueled the arguments of opponents. One opponent study followed the therapy of 2000 workers for one year. No differences were found to exist in functional ability, pain, disability level or quality of life. Functional restoration remains an important rehabilitation principal. Functional restoration is a well-established and successful therapy choice. However, further research is necessary to address the outcome measurements because they need to be clarified and perhaps revised. Table 23. Functional Restoration focus pointsTreatment is focused at the disability levelFunctional ability and pain are addressedImproved function leads to less pain Table 24. Evidence for functional restorationAuthorTherapy UsedConclusionNotesCutler et al., 1994Functional restorationPatients return to workLevel IIAlaranta et al., 1994Functional restorationImproved R.O.M strength and enduranceLevel IISinclair et al., 1997Functional restorationFunctional restoration does not improve subjective measuresLevel II The general medical approach is extremely lacking in many areas. There is very little emphasis on return to work, the patient is passive through this process and there is no attempt at patient education. Pain reduction is emphasized, but mobility, strength, coping skills and disability issues are not addressed. Back schools have been shown to be very effective. A Back school is a program set up by the physical therapists of a clinic to educate patients on the benefits of using the back correctly. The content of each back school varies. The issues of concern in a back school tend to be, Correct Posture, Stability of the trunk, Body Mechanics, Activities of Daily Life and The modification of activities. Back school can begin at any stage including before there is a problem, as a preventative measure. This approach emphasizes the areas of patient education, self-help, and patient participation. Mobility increases and coping skills are a few of its strengths. Functional restoration programs emphasize the same areas as Back schools, but is much stronger across the board concerning the goals of therapy. In Appendix 7.4, an illustration of a comparison of chronic pain approaches is presented. 3.3.4 Psychological Approaches The aim of pain management is not to decrease the pain, but rather to have the patient take responsibility for the management of their pain and functional disability. Physiotherapists can use psychological measures in the treatment of chronic pain by reducing anxiety and depression. Chronic pain is as much as a psychological as a physiological phenomenon, psychological strategies is helping the patient to control and cope with it in many instances. The physiotherapist should develop a supportive relationship with the patient. Physiotherapists may use psychological strategies to help their patients, either as the sole treatment technique or inclusion into a program of physical treatment. The physiotherapist must recognize when the patient needs to be referred to a psychiatrist or a clinical psychologist. 3.3.4.1 Behavior Modification Approach The behavior modification technique is focused on changing pain behavior rather than pain perception. Behavior modification is a technique whereby behavior, which is approved of is rewarded while behavior, which is disapproved of, is ignored. In this way, behavior is shaped. The patient may be fully aware of the aims and objectives of the behavior modification program and may have even helped to devise it with the physiotherapist. Also the practice of behavior modification may be covert without the patients awareness. In a study by Harding and Williams, (1995) a cognitive-behavioral program was developed for the treatment of pain within a physiotherapy perspective. The program included the setting of realistic goals, the pacing of activities to avoid the over-activity/under-activity cycle, education, self-management and the challenging of unhelpful cognitions. Pain was never denied but pain behavior was never rewarded. However, exhibiting pain behavior is considered to be normal for chronic pain patients (Waddell, 1998). French (1997) states that: Unless therapists are compassionate and sensitive to the needs of patients, it is likely that they will be unaware of many situations in which the interests and welfare of their patients are under threat. If they do not posses the virtue of discretion, they may not recognize those situations in which confidentiality is called for. Unless therapists possess a certain measure of courage, they may lack the resolve to carry through morally appropriate courses of action in circumstances where doing so may make them unpopular, or place their own interests at risk. Thus, moral virtue plays an important part both in the initial recognition of a moral situation, and in the pursuit of action, which has been identified as morally appropriate. Van Tulder et al (2000) concluded that behavioral treatments seem to be effective treatment for patients with chronic low back pain. Further research needs to be carried out to determine what types of patients benefit most from which type of behavioral treatment. Table 25. Evidence for Behavior ModificationAuthor(s)Therapy UsedConclusionNotesHarding, Williams, 1995Cognitive Behavioral ProgramPain was never denied & pain behavior not rewarded.Van Tulder et al, 2000Behavioral TreatmentEffective for chronic low back patients. Level I 3.3.4.2 Cognitive and Cognitive-Behavioral Approaches Cognitive approaches put more emphasis on mental events to improve the confidence and morale of patients who have depressing thoughts about their condition. Cognitive-Behavioral methods help patients to reorganize the way they think about their pain and at the same time change their pattern of behavior. Fear and lack of confidence are responsible for reduced activities and not ill related physical restrictions (Feuerstein, Beattie, 1995). The reduced amount of activity seen in chronic pain patients, due to fear and anxiety towards any kind of movement is known as kinesiophobia. Physiotherapists frequently tailor programs for chronic pain patients aiming at an increased exercise tolerance. Carefully graded exercises reduce their pain. If appropriate, health education and other treatments go along with it. In many cases the improvements are equally or more concerned with psychological change (French, 1997). Participating in such programs, patients may become confident in their ability to cope with their condition and define themselves as well rather than ill. Nicholas, Wilson and Goyen (1992) investigated the relative efficacy of cognitive-behavioral group treatment, including relaxation training, in comparison with a control condition in a sample of 20 outpatients with chronic low back pain. Both conditions received the same physiotherapy back-education and exercise program. The combined psychological treatment and physiotherapy condition displayed significantly greater improvement than the attention-control and physiotherapy condition at post-treatment on measures of other-rated functional impairment, use of active coping strategies, self-efficacy beliefs, and medication use. These differences were maintained at 6-month follow-up on use of active coping strategies and, to a lesser degree, on self-efficacy beliefs and other-rated functional impairment. Sonderlund and Lindberg (2001) described a model for an integrated physiotherapy/cognitive-behavioral approach in the analysis and treatment of chronic Whiplash Associated Disorders (WAD) patients, as well as to evaluate the effectiveness of this approach in three experimental single case studies. The results showed that physiotherapy integrated with cognitive behavioral components decreased the patients pain intensity in problematic daily activities. Dahl and Nilsson (2001) investigated the effects of cognitive behavioral work site interventions on a group of 29 practical nurses being at risk for developing chronic pain. Results at 4 and 8 weeks and at 6, 12 and 24 month follow-ups showed improvements for those individuals receiving the active treatment with regard to the reduction of use of pain-killers, perception of ones self as being sick and the fear-avoidance response to work-related activities. A preliminary conclusion was that this short-term work site program for the prevention of chronic pain for individuals at risk might be a promising development in the treatment of pain. Linton and Andersson (2000) compared the effects of a cognitive-behavior intervention aimed at preventing chronicity with two different forms of information. The main focus was to prevent long-term disability by changing patients behaviors and beliefs so they can cope better with their problems. Aiming at preventing long-term disability, the key outcome variables at the 1-year follow up assessment were pain, function, fear-avoidance beliefs, and cognitions. This study demonstrates that a cognitive-behavior group intervention can lower the risk of a long-term disability developing. In a systematic review by van Tulder et al. (1996) there was limited evidence that cognitive behavioral therapy was an effective short-term treatment for chronic low back pain. There was no evidence that one type of cognitive-behavioral therapy was more effective than others. Table 26. Cognitive and Cognitive-Behavioral Approaches Author(s)Therapy UsedConclusionNotesFeuerstein & Beattie, 1995Improving ConfidenceFear and lack of confidence responsible for reduced activity.Level IINicholas, Wlison & Goyen, 1992Cognitive-Behavioral GroupTreatmentCombined psychological treatment with physiotherapy lead to a greater improvement.Level IISonderlund & Lindberg, 2001Integrated Physiotherapy/ Cognitive- Behavioral ApproachDecreased patients pain intensity in problematic daily activities.Level IILinton & Andersson, 2000Cognitive-Behavior InterventionLowers the risk of long-term disability development.Level IIVan Tulder et al, 1996Cognitive-Behavioral TreatmentLimited evidence as an effective treatment. No evidence that one cognitive-behavioral therapy is more effective than other type.Level IDahl & Nilsson, 2001Cognitive Behavioral Work Site InterventionPromising development in treatment of pain.Level II 3.3.4.3 Group Therapy Technique Meeting other chronic pain patients may give another perspective of their suffering. Other group members may act as positive role models. Some people might be motivated by competition that the group experience may provide and others may feel less anxious and depressed by sharing their experiences within a group (French, 1997). The functioning of the group may have important effects in reducing the patients perception of pain or helping him or her to cope with it. Patients with chronic pain, who found no relief in conventional physiotherapy treatments, were helped by taking part in a fitness program that focused on exercises that were directed away from their area of pain (Williams, 1989). Activity, optimism and effort were rewarded, whereas any demonstration of pain behavior was ignored. According to Williams most of these patients showed improvement within 3 weeks. She believed that focusing on physical activities is particularly helpful as most patients strongly resent the suggestion that their pain is all in the mind. No counseling was given and professionals such as clinical psychologists were not involved. The patients view of the physiotherapist as someone, who was concerned with his or her physical condition, seemed to help the program work. However, this goes against the views of the multidisciplinary treatment of chronic pain that involves psychologists and counselors that are considered as an integral part of the group approach for the assessment, prevention, and treatment of chronic pain (Waddell, 1998) Even though group dynamics can have a positive effect on a chronic pain patient. Some group members may feel pressure to conform to the group norm or some members may succeed in gaining the attention of the physiotherapist while others may feel left out. Some patients do not feel content or confident in a group. The wishes of these patients should be respected; any attempt to force them into a group situation is likely to be counter-productive (French, 1997). Table 27. Evidence for Group TherapyAuthor(s)Therapy UsedConclusionNotesWilliams, 1989Group Fitness ProgramExercises may divert the patients attention from the pain. Level II 3.3.4.4 Counseling Technique There is evidence that training in counseling skills can enhance the practice of health care professionals (Ryden et al, 1991). Counseling skills in physiotherapy practice focus on the relationship between the therapist and the patient. All health professionals should have sufficient understanding of psychological issues to provide understanding, reassurance and support for the patient. Physiotherapists should be able to recognize those few patients who require referral for a more thorough psychological assessment and treatment. The therapist creates a warm and compassionate relationship and environment in non-directive counseling. There is little interruption or guidance from the therapist as the patient is able to talk and work through his or her problems (Burnard, 1992; Swain, 1995). The patient may come to the conclusion that the best way to cope is to try to ignore the pain, or that the pain is being maintained under the patients control by avoiding boring or difficult tasks. The Physiotherapist takes a more active role in cognitive counseling, concentrating on the patients thoughts and feelings in relation to his or her pain and attempting to change them. The negative perception, which the patient has, of his or her pain may be causing anxiety and depression making the pain worse. It is the task of the therapist to help such patients realize that they are responsible for their own thoughts and feelings. The patient should be helped in developing a more positive outlook by a suitable treatment program being created by the physiotherapist (Niven & Robinson, 1994; Williams & Erskine, 1995). Table 28. The doctor-patient relationship (Balint, 1964)Listening and taking time to listen are importantWarmth: Demonstrate an unconditional positive regard for the patient as a human being not judgment or like/dislike.Accurate empathy: convey to the patient that you have an accurate understanding of their problem and experienceGenuineness: be yourself; do not hide behind a professional faade. This does not mean disclosing personal details about yourself.Provide continuity of support over timeDraw the line between support and counseling and do not try to be an amateur psychiatrist. Table 29. Evidence for counselingAuthor(s)Therapy UsedConclusionNotesRyden et al, 1991CounselingCan enhance the practice of health care professionals.Level I 3.3.4.5 Alternative Approaches 3.3.4.5.1 Relaxation Relaxation may be used as a technique in chronic pain treatment to reduce stress, anxiety and depression (French, 1997). Relaxation reduces activity in the sympathetic and motor nervous systems (Melzack & Wall, 1988). The mechanisms of pain reduction may be physiological, by reducing muscle tension. The cognitive function is when the patient manages to direct his or her attention away from the pain. There is considerable evidence that relaxation training brings about pain reduction (French, 1997). A study of Nicholas, Wilson and Goyen (1991) compared operant-behavioral and cognitive-behavioral treatments for 58 chronic low back pain patients. The 4 treatment groups consisted of cognitive (with and without relaxation training) and behavioral treatment (with and without relaxation training). All groups received the same physiotherapy back-education and exercise program. The 2 control conditions consisted of attention (physiotherapy plus discussion sessions) and no-attention (only physiotherapy). The behavior conditions improved significantly more than the cognitive conditions from pre to post treatment on the self-rated measure of functional impairment. This difference was not maintained at 6- and 12-month follow-ups. Progressive relaxation training was found to make little contribution to either cognitive or behavioral treatments. Carroll and Seers (1998) reviewed systematically the effectiveness of relaxation techniques in the management of chronic pain. Nine studies involving 414 patients were critically appraised. There was insufficient evidence to confirm that relaxation can reduce chronic pain. Schofield and Davies (2000) compared in their study of chronic pain the use of a sensory environment against a traditional relaxation program used in a hospital pain clinic. The patients who attended the sensory environment did slightly well than those who attended the traditional relaxation program in terms of self-efficacy. There are conflicting ideas concerning the benefits of relaxation techniques in the management and treatment of chronic pain patients. Further research in sensory relaxation should be developed. Table 30. Evidence for RelaxationAuthorsTherapy UsedConclusionNotesNicholas, Wilson & Goyen, 1991RelaxationMade little contribution to either cognitive or behavioral treatments.Level II Carroll & Seers, 1998RelaxationInsufficient EvidenceLevel I Schofield & Davies, 2000Sensory Relaxation vs. Traditional RelaxationSensory relaxation program more effective than traditional relaxation program.Level II  3.3.4.5.2 Biofeedback This technique is used if it is thought that the patients pain is the result of physiological processes such as tense muscles (French, 1997). The patient may learn to control his or her physiological state by getting feedback (Hanson & Gerber, 1990). There is conflict in the efficacy of biofeedback in the treatment of chronic pain. Chapman (1986) reviewed the literature and found no advantage for biofeedback combined with relaxation over relaxation alone. Smith (1987) found that the two techniques in combination were more successful than either technique in isolation for reducing headache. Spence et al (1995) examined the relative effectiveness of EMG biofeedback, applied relaxation training and a combined procedure in the management of chronic, upper extremity cumulative trauma disorder. The strongest short-term treatment benefits were shown by patients receiving applied relaxation training on measures of pain, distress, and interference in daily living, depression and anxiety. By 6-month follow-up, differences between treatment groups were no longer evident. Table 31. Evidence for BiofeedbackAuthorsTherapy UsedConclusionNotesHanson & Gerber, 1990BiofeedbackPatient may learn to control their physiological state.Level IIChapman, 1986BiofeedbackNo advantage when combined with relaxation.Level ISmith, 1987BiofeedbackCombining with different techniques is more effective.Level ISpence et al, 1995Biofeedback vs. RelaxationRelaxation was more effective.Level II 3.3.4.5.3 Other Alternative techniques Different psychological methods can be used to help a person being at risk of chronic pain. Some physiotherapists may become acquainted with techniques that include: Psychoanalysis Assertiveness training Visual imagery Acupuncture Aromatherapy Homeopathy Reflexology Meditation It is a matter of contemporary discussion if each of these different alternatives work and whether they are purely placebic in the treatment of the chronic pain patient (French, 1997; Waddell 1998). Many researches found that combining several methods for the relief of pain leads to greater success rate than relying on just one. However, it would be more effective to recognize the function of these alternative therapies in individual patients and then plan a specific treatment for them (Main & Spanswick, 1998) 3.3.5 Relapse Management It is almost inevitable that a patient with chronic pain will experience a relapse or an exacerbation of the pain problem during rehabilitation. An exacerbation does not indicate failure of the treatment or the method or confirm that the patient is powerless to affect a change in their condition. An exacerbation can be looked upon as an opportunity to assess and improve management skills. The therapist can assist the patient by identifying the situations that are demanding and by developing strategies to cope with these situations. Plans for resumption of activity after a recurrence of symptoms are critical. Getting the patient back to activity is extremely important, and a plan is necessary. Even if it does not cover all eventualities, having a contingency plan to deal with problems can help the patient preserve an impression of control. For those with chronic pain, rehabilitation can be long and convoluted so planning helps to show the way back to the path of progress. Physical therapists work with a framework for relapse management that is patient- responsive, time-dependant and goal-oriented. Rehabilitation involves overcoming physical and psychological obstacles. The physical therapist is indispensable to the patient during the course of pain management. Physical therapists attempt to alleviate the patients distress and feelings of helplessness as well as guide efforts toward a return to activities. Their rehabilitative methods and fundamental concern with restoration make physical therapists essential to the multidisciplinary team required for effective pain management. Table 32. Relapse Management Focal PointsRecurrences of the pain problem are normal.Planning for recurrences is essential to managing rehabilitation.Management should be patient-responsive, time-dependant, & goal oriented.A quick resumption of activities is consistent with a successful treatment. 3.3.5.1 Relapse contingency plan It is very probable that the patient will experience a set back during the rehabilitation process. Even when the health care given is effective, there is no evidence to suggest that relapses are preventable. With this in mind, there are certain plans that need to be in place before a problem occurs. A plan should be drafted as soon as possible after the time the therapist and the patient enter into an agreement for rehabilitation. It should be explained to the patient, from the beginning, that set backs are normal. They are no reason to abandon the efforts made or to discontinue physical therapy and try another type of medical intervention. A time schedule should be set for the resumption of activities (preferably resuming near the level attained when the pain occurred), if the activities are to be decreased or halted. The pending goal schedule may require amendment or revision. The degree of pain, over the normally experienced level should be noted. What interventions will be used to alleviate the pain? Examples may be oscillations or active assisted range of motion, in the pain-free range. Avoid long-term maintenance therapy as it may have the result of removing responsibility from the patient for their rehabilitation. It may create a passive situation, of Healer and Care receiver. It is important that the patient be reminded of the progress that has been made is their achievement. They should be brought up to date on their situation, as it is perceived by the therapist with the caution that fitness level decreases relatively rapid. A need exists for more research to be done on how to maintain any improvements made and on ways to prevent exacerbations of pain symptoms from occurring. Table 33. Relapse Contingency Plan Focal PointsHave a plan ready for recurrences of pain problem.Set a time schedule for the resumption of activities.Long-term maintenance therapy releases patients from their responsibilities for rehabilitation. 3.3.5.2 Taking responsibility It is imperative to the rehabilitation process that patients take responsibility for their personal clinical progress. Functional progress depends entirely on the patients motivation, persistence and participation. The patient must make the effort. Therapists and the other healthcare professionals have the role not as healers, but as helpers, facilitators of the patients efforts. Ultimately, the patient must accept, and the healthcare professional must relinquish, the main responsibility for rehabilitation (Waddell 1998). Table 34. Taking Responsibility Focal PointsThe patient must accept, and the clinician must relinquish responsibility for rehabilitation.Progress depends on the motivation, persistence and participation of the patient. 3.3.6 Chronic Pain Management Most pain management programs combine cognitive, behavioral, and alternative techniques. In a review by Flor et al (1992) 65 reports of multidisciplinary treatment for chronic low back pain concluded that pain management programs can improve pain, mood and quality of life, and that these results are stable over time. Most studies on pain management have ignored the major problems of chronic pain patients failing to comply with treatment, dropping out and relapsing (Turk & Rudy, 1991; van Tulder et al, 1996). In a systematic review of occupational outcomes by Scheer et al (1997), little evidence was found that patients with chronic low back pain return to work after participating in pain management programs. Many of the proposed psychological treatments for chronic pain are encouraging. Further research is needed to determine if there is a long-term advantage of any particular approach to chronic pain, or if psychological treatments are more effective than exercise therapy and/or passive physiotherapy modalities. Table 35. Results for Chronic Pain ManagementAuthor(s)ApproachConclusionsNotesFlor et al, 1992Multidisciplinary Treatment for Chronic Pain ManagementCan improve pain, mood and quality of life.Level I Turk & Rudy, 1991; van Tulder et al, 1996Chronic Pain ManagementIgnore patient compliance, drop out & relapse.Level I Scheer et al, 1997Chronic Pain ManagementLittle evidence of chronic pain patients returning to work.Level I 3.3.7 Summary of Treatment studies Psychological and social strategies can be used to reduce the patients perception of pain and/or to help the patient to cope with it. Strategies can be combined with each other or with the more familiar physical approaches of physiotherapy practice. Treating psychological and physical aspects of chronic pain is inseparable. It is of vital importance that physiotherapists understand the complex nature of pain and treat the patient with this in mind. 3.4 Discussion to physiotherapy for Chronic Pain Caring for and managing chronic pain patients requires attention to multiple areas concerning the patient. The areas of concern are to be addressed with the use of multidisciplinary techniques. The use of many variously directed techniques is important to having an influence on the entire patient and the quality of their life. The effects rendered by the respective methods are evidence of the clinical relevance of these techniques. Treatment of chronic pain consists of addressing the functional ability; the patients beliefs about their pain and communication with others in the patients support network. As is noted in Rehabilitation Strategies, an exercise program can reverse the problems attributable to deconditioning. A decreased fitness level and decreased functional ability are examples of the problems attributable to deconditioning. The message here is that a person with poor physical conditioning and related problems should exercise in order to positively influence their pain, fitness level and physical functioning. Exercise can be done in a wide range of ways one example is Hydrotherapy. Hydrotherapy supports the advantages of exercise with the added benefit of warmth by immersion in water, which is known to aid in the relief of pain via the gate theory. Hydrotherapy is a good example of collaboration between the contemporary view of graded activity for the treatment of chronic pain and the traditional practice of conventional therapy. Although the practice of activity is the more appropriate of the two methods, increasing the patients comfort while simultaneously increasing the patients activity is an effective compromise. Two more examples of exercise programs are Functional Restoration and Active rehabilitation. Functional restoration focuses on the patients disability on a higher level than an isolated exercise. It is not only focused on whether activity is occurring, but how well the activity is being carried out. Active rehabilitation serves to help the patient see a purpose to exercising. They are not asked to attempt to see the relevance of quad sets in their daily lives, but they are shown the importance of proper body mechanics, improved gait and proper posture. There are still questions and debates on the concepts of rest or activity in response to pain. More research needs to be done to answer the outstanding questions. Research is also needed to offer therapists insight into the most effective treatments in an effort to maximize time use and aide the patients speedy recovery, among other concerns. Although rest is recommended during the acute stage because exercise shows no effects during this period, there is no implication that the rest period should be extended past the acute stage. Resting in response to chronic pain can only serve to increase the severity of the condition. Remaining active is a much better response to chronic pain episodes. The body is adaptive. It will perform, to the best of its ability, what it is asked to perform. If asked to do nothing, the body will comply, with consequences. Getting patients moving and active again is one part of a many faceted treatment plan being employed. Increasing a patients activity thereafter is another. During rehabilitation, increasing activity based on a time schedule and without regard to symptoms helps to focus patients on abilities regained, goals that have been realized, as well as goals that have yet to be attained. This reduces the focus on symptom dynamics, which reinforces a new cycle of reduction of the pain experienced and reduced attention to pain. During the rehabilitation process, recurrences of the pain are to be expected and thus planned for. Part of this planning should include an explanation to the patient about what to expect during therapy and what recurrences signify to the treatment process and the patient. Pain recurrences, though not helpful, are normal and manageable. There is overwhelming scientific evidence to support the concept of exercise as an effective tool in the management of chronic low back pain. When supervised by physiotherapists the functional outcomes such as reduced absenteeism, faster return to work rates and reduced disability have been corroborated. As therapists search for ways to improve the treatments they use, they of course, consult traditional medicine. However, physiotherapy is beginning to take a more detailed look at what holistic views have to offer for patient treatment. Biological, psychological and social factors strongly influence the pain process. Understanding those factors assists the physical therapist in evaluating and treating chronic pain patients. The combination of physiotherapeutic treatments with psychological techniques displayed significantly greater improvements than physiotherapy alone. Apparently, alternative views of treatment such as relaxation, biofeedback, imagery or cognitive-behavioral therapy when used in conjunction with other contemporary treatment types can have a positive impact on the outcomes of the rehabilitation process. For example, it is necessary to adjust what the patient believes about the pain they experience as well as their physiological and behavioral responses to it, in order to optimize rehabilitation. Unhelpful beliefs hinder rehabilitation. Cognitive-behavior groups also report significant decreases in risk perception and demands for subsequent therapy. Those patients who receive only limited information in addition to physical therapy have clearly increased needs for physical therapy and care from a physician after the regular treatment period. It is clear that providing the patient with sufficient, pertinent information has a significant influence on the outcome of therapy. This approach might be applied in primary care settings with an aim of preventing chronic problems. This kind of approach is valuable for patients with chronic pain, whom conventional medical treatments did not help. It improves their daily functioning and hence, their lives. A question still outstanding, is which patients benefit most from this form of treatment and how can clinicians identify them? To provide an answer to this question further research has to be done. When relaxation is included in a treatment plan, the effects of the therapy are observably increased. Relaxation was shown to have a significant contribution to physical therapy, if measured right after treatment. Although progressive relaxation has, yet to demonstrate a contribution to cognitive or behavioral treatment viewed from a long-term perspective the utility of this method may become clearer through further study. Another area of debate is the treatment and management of pain. There is at the present time a lack of support for many of the physical methods of pain treatment traditionally used, but a lack of backing does not take away from the fact that these methods are useful and practical to the patient and the therapist; and thus have a place in the treatment of chronic pain patients. These methods can influence the quality of life for patients. These programs are important because they help to shift the patients attention from the perception of pain to coping with pain. Instead focusing on their own disabilities, the patient becomes more aware of the activities that still are possible. In addition, when used in an outpatient setting, the costs of care can be reduced. Therefore, as therapists continue to search for ways to maximize the benefit they can offer their patients and this searching leads to the cooperation of many types of professionals and treatments, there is adequate reason to consider treatments that dont immediately fall into the established categories. The hope is that clinicians will not be content with the status quo of this issue and will lobby for more complete and definitive answers through continued research. 3.5 Conclusion to physiotherapy for Chronic Pain The next paragraphs are intended to culminate the therapy section. An alternative explanation for the observed results follows. The results gathered from the mentioned techniques further illustrate the inadequacy of the current, traditional, methods of treating patients afflicted with chronic pain. The current shift from the traditional methods of treating chronic pain is an indication of the ineptness of these methods and explanation for the dissatisfaction of clinicians. More effective, more dependable and predictable methods are necessary, that much is now clear. One possible and succinct interpretation is; without the timely recognition of the development of chronic conditions, the patient will be made to unnecessarily suffer. A treatment plan without the biopsychosocial approaches lessens the impact of therapy. Without the inclusion of exercise, the chronic condition will worsen. The omission of functional restoration avoids addressing the functional abilities and the disability level of the patient. Failing to properly inform the patient and not planning for relapses is not only counter productive, but destructive to the rehabilitation process. There are numerous treatment options for the treatment of chronic pain and the management of chronic pain patients. Some important points to remember are: (1) The total patient and the areas that concern the patients well being should be considered. The physical areas of functional capabilities are very important but the biopsychological needs should not be overlooked. (2) Therapists should also address the vocational concerns of the patient, according to the outline from the New Zealand guideline group. This must be done in order to have a long-term effect of the patients condition and living situation. (3) No longer should the patients pain and its treatment be regarded as the primary goal in the care of chronic pain. Patients require clear and unambiguous advice. Professional advice to rest or stay active is tremendously important with respect to how patients respond to their back pain. The goal is to maintain the patients ordinary activities or return the patient to their ordinary activities as quickly as possible (Waddell, 1998). What is important is this achieves the desired functional outcome with cost-effectiveness by reduced use of healthcare resources. Each of the presented treatments has been supported scientifically, which lends backing to the statements made about their efficacy in each respective section. The clinical relevance of each is demonstrated by the influence each treatment has on chronic pain and the condition(s) associated with chronic pain. The application of these results is seen in the treatment plans developed, the information given to the patient and the manner in which the therapist manages the patients presenting with chronic pain. After extensive research, the conclusion is that the results of the treatments presented uphold and support the hypothesis that treatment plans based on functional impairments increase the quality and efficacy of patient rehabilitation. As more research is done, the conclusions will affirm activity as the appropriate way to treat chronic pain. 4.0 Conclusions and Recommendations Introduction With the bulk of material covered, a summation is necessary to provide a concise review of the important points of the research reviews. These are intended to provide reflection on the covered topics and will be taken further to a discussion of ideas formed and created during the research process. The discussion over the discoveries and conclusions of the reviewers describes the enriching findings from the research. For the physiotherapist, a series of recommendations will list treatments options that are backed up by sound clinical reasoning, though may or may not have scientific justification. An importance will be placed on practical implementation of the methods listed. Further, they will be listed in order of clinically reasoned importance. A number of points for further research were discovered through the research, as well. These opportunities are provided at the end of the chapter. It is intended to provide opportunities for further study as well as illustrating the future of the field of chronic pain. 4.1 Conclusion of Definition A clear definition of chronic pain has clinical relevance with formation and adjustment of treatment programs. Understanding the nature and characteristics of chronic pain is the first step in recognizing a patient who is beginning the long slide into the syndrome. However, these qualities can be deceptive and difficult to identify objectively. The difference between acute pain and chronic pain provides a valuable distinction. Acute pain has pathologic origins, a rapid onset and a duration associated with the involved structure. Chronic pain on the other hand shares few of these characteristics. Chronic pain is more insidious in its onset, has no diagnosable origin and the duration lasts far beyond the healing time associated with the impaired tissues. There are various sources available reflecting differing degrees of cultural influence. This is characteristic of the elusive nature of assessing and diagnosing chronic pain. From the various sources sited the definition of chronic pain is: Pain lasting longer than the normal healing time expected for involved tissues, usually three to six months. This indicates the inclusion of psychosocial factors, which are dependent on cultural aspects. The display of pain behavior is based upon learned social interactions. As shown in the biopsychosocial model, the pain behavior and social interactions compose the largest portions of the model. The pain is expressed through the attitudes and beliefs of the patient and any psychological stress experienced. As the cultural and social interactions dictate further expression there must be made. A pragmatic approach to chronic pain is dependent on the recognition of these social factors. While a multicultural approach was stressed in the outset of the research for a definition, the exclusion of cultural influences is not possible in considering chronic pain. 4.2 Conclusion of Assessment Many assessment techniques and forms were discovered in this search, with little emphasis on prevention found. The opinion was therefore formed that skilled knowledge of the appropriate assessment tools would provide preventive intervention. In other words, knowing how to assess a chronic pain patient will enable the physiotherapist to identify patients at risk of becoming chronic pain patients. Identification of psychological and social warning signs can be viewed as a primary goal of assessment. Allowing for treatment goals to be set towards their attention. Fortunately, several assessment tools and questionnaires are available to reach this aim. The pain drawing is a simple and understandable questionnaire regarding a patients pain. It provides pragmatic insight to the patients reactions and beliefs from their pain. The drawing provides a means for the patient to describe their pain, while providing the therapist with useful insight to the patients psychological state. The repeatability of the drawing has been proven in studies to be accurate and reliable as a means of pain description. The visual analog scale (VAS) is a very well known and simple questionnaire regarding the patients pain. While its original form is text, it can be clinically performed verbally. Studies of this assessment tool show that it is statistically consistent in a wide patient population. However, interestingly, it was notably less consistent with chronic pain patients. As the previous tools addressed rough descriptions of the pain, the pain disability index (PDI) provides insight to the functional limitations experienced because of pain. It is a self-reporting index the patient fills out on their own. The answers provided cover a broad spectrum of activities of daily living. The PDI has been shown to be statically valid in its repeatability and clinical validity. The multidimensional pain inventory is another assessment tool, which provides information regarding the psychological responses of the patient to the pain. This questionnaire is time intensive for both the patient and therapist to complete and analyze. This time investment can be justified by the applicability of the information to all fields. However, being new, statistically reliable studies have not yet been published on its reliability. The New Zealand Guidelines Group, commendably, assembled a questionnaire and list of warning signs, or so-called yellow-flags. They provide a summary of risk factors for patients developing a long-term disability. One large benefit to this system is it can be applied to a large patient population. However, a skilled, time intensive interpretation is required. The breadth of its scope covers several social categories uniformly, without emphasis on one or another. The identification of yellow flags should be done with a low-inclusion threshold. The risk of under-identification is reinforcing disabling factors, creating a chronic situation. While the over-identification of yellow flags may lead to the wasteful use of resources, these costs are negligible compared to the long-term treatment arising from under-identification. Table 1. Summary of Assessment tools ResearchThere is no one perfect, all encompassing, assessment tool.Each tool, or method, has its own area of emphasis.Understanding and appropriate application of several different tools is the surest method of a comprehensive assessment.Combining an accurate knowledge of chronic pain and the assessment tools, allows for preventative measures to be taken.Chronic pain is a complex combination of physical, psychological and social factors of the patient.  4.3 Conclusion of Treatment The most effective treatment for chronic pain is based upon improving the functional level of the patient. Exercises and activity programs must be aimed at improving the participation. An emphasis on the reduction of pain only re-directs the attention of the patient away from functionality. Studies have shown that exercise programs are effective in restoring functional levels in patients. Participants in exercise programs with chronic back pain were shown repeatedly to have lower incidents of absenteeism at work. Higher compliance was found in patient groups participating in guided exercise programs. The cost of exercise programs was offset consistently by the loss of wages and productivity in patients. Group exercises were the most cost-effective, by spreading the administrative costs over several patients. Exercise therapy has been clinically proven to be more therapeutic than other physiotherapy interventions for chronic pain management. Patients experiencing chronic low back pain who participated in long-term studies (over a year) had decreased absenteeism and higher work performance scores. The return to work rates was increased. General Exercise has been shown to be the most advisable long-term management tool available to physiotherapists. The expenses for administering an exercise program are decreased through group sessions led by a physiotherapist, as opposed to individual treatment. These costs are minor in comparison to reduced wages and decreased productivity at work. Functional exercises emphasize the obstacles in daily living faced by the patient in chronic pain. Attention of the patient is diverted away from the pain, breaking a troublesome focus on the pain. Further, studies showed goal oriented functional exercises reduce the kinesiophobia experienced by the patient. Manual therapy and hydrotherapy are two effective alternatives available in combination with exercise therapy. Manual therapy should be used with concern towards increasing the functional level of the patient. Hydrotherapy was also shown to allow functional exercises to be performed in a low impact environment. Passive modalities, such as heat, cold, TENS and ultrasound have been shown to have no long-term benefit in the condition of patients with chronic pain. There is insufficient evidence to indicate the usage of these modalities in the long-term treatment of chronic pain. TENS can be considered for short-term usage in increasing the patients ability as supported in studies. 4.4 Discussion of Findings Through the research process there were several discoveries, or moments of enlightenment, for the reviewers. These findings covered a variety of topics and specificity to the treatment of chronic pain in physiotherapy. From the formation of the original goals of the research to the realization of the project, conclusions led to the shifts and changes in the direction of the research. As these findings were the most enriching part of the research, they are discussed below. 4.4.1 International Findings The initial objectives of the research were to provide an international perspective on the definition, assessment and prevention. The goal was to compile a prevention program from a collection of resources derived from various western countries. Our division of research was based upon countries (United States, Canada, New Zealand, Australia, United Kingdom, the Netherlands and Germany). It soon became clear that the most modern and applicable research on the theory of treatment was being done with the combined efforts of experts from many nations. A division of country perspectives was not possible when papers, texts, and articles were co-written by experts from Canada and the UK, for example. Indicating the progress of the theory of chronic pain was not centered in any one country but representative of a collective whole. There is however, a more distinct difference in the clinical practice of chronic pain treatment. Harder to discover through research, personal contact with experts provided the mass of our information in this field. Practical distinctions though do still exist (i.e. the reliance on pharmaceutical intervention in the U.S.). A selected few are described below. 4.4.1.1 Great Britain (UK) In the mid nineties, the U.K. moved away from treating pain with rest. They are currently in agreement with the concept of treating the affects of chronic pain with activity, according to the research found. The level of participation throughout the country though, or the number of participating facilities could not be found or attained through research or personal contact. 4.4.1.2 The Netherlands In principal, the Netherlands made the move from the passive treatment of pain symptoms to the more patient-oriented, graded activity approach some time ago. The problem is that what is advocated by the official philosophy for the treatment of chronic pain, has not yet become the standard of practice in the clinics. For example, a clinic in Eindhoven may practice getting the chronic pain patient moving again as quickly as possible; but another clinic in Zeeland may still apply the conventional, passive physical treatments. Although it is agreed that treating chronic pain with activity is better than treating it with passive modalities (due to the inefficacy of passive modalities and their propensity to exacerbate the problem of chronic pain) it is not yet the standard Practice. It can be said that participation has yet to be reconciled with the official philosophy. 4.4.1.3 Germany In Germany, the system of health care has also acknowledged that the care of chronic pain individuals is best done with a focus on activity. In fact, therapists from Germany and the Netherlands have many of the same ideas on the subject of chronic pain and its consequences. They agree on an increasing amount of activity approach to chronic pain treatment. The German health care system is currently taking steps to implement the concept of multidisciplinary care. This process is moving quite slowly. In the U.S. the multidisciplinary team is recognized as the Physician and the supporting staff, the physical therapist, occupational therapist etcetera. They communicate with one another by telephone, fax, computer and even through the patient, who carries his/her medical records, prescriptions and referrals to the next place of treatment. Everyone involved with the care of this patient is kept aware of the present status as well as the planned treatments for this patient. The caregivers are not in the same facility. In Germany, the goal is to create facilities where the collective team of healthcare professionals is all under one roof. These facilities are to be led by a team of physicians, who direct the efforts of the rest of the team, which is to be comprised of physical, ergonomic, and sports medicine therapists. (There are also plans to add orthopedic surgeons to this list). There are a few examples of this type of facility already in practice but the process of founding more by changing the existing clinics into Multidisciplinary Centers is proving to be a formidable logistics challenge. This is the reason the process, though making progress is moving very slowly. 4.4.2 Theory versus Practice The development of theory is occurring at a much faster rate than can be implemented by the healthcare systems of various countries. The gap that has developed provides promise for more timely prevention, accurate assessment and effective treatment for patients suffering from chronic pain. Worthwhile research on the implementation of the theory can still be performed. 4.4.3 Assessment versus Prevention Another global discovery of the group was the inability to distinguish between accurate assessment and prevention. The information garnered was a warning sign for use in prevention. It was therefore concluded a shift of subjects should be made, from prevention to treatment. This discovery was supported by the focuses of research being done in the field. 4.4.4 Compensation Issues Yet, another discovery of note was the impact of compensation on the rate of recovery. As evidenced in effectiveness studies, the United States had higher rates of return to work than countries in Europe. It was surmised that the lower compensation rate of workers was of pivotal importance. The workers in countries with greater social support experienced lower rates of return to work. 4.4.5 Application of Electrotherapy A final point made clear in our research was the importance of moving the treatment parameters in chronic pain patients towards the functional limitations. Evidence unequivocally found, at best, no benefit to the use of passive modalities such as TENS in the long-term treatment. Several resources showed damaging effects from their application, as they reinforced the chronicity of the pain. Though there is also evidence showing that its application in the short term, provides respites for the patient and thereby enables a higher functional level to be attained. The opinions of the reviewers are indicative of the modern thinking about electrotherapy in chronic pain treatment; a split exists and both parties are strongly fixed in their positions. Optimally the dangers and benefits need to be accurately assessed before inclusion into a treatment program. The inclusion of supporting and countering evidence is intended to provide evidence to support this judgement. 4.4.6 Conclusion over global findings With the inclusion of the numerous factors involved, treating chronic pain is not a simple, linear process. It involves assessing physical, psychological and social aspects. Intervention with every category is thus indicated. As with any treatment, reassessment must be done regularly to emphasize problematic areas. Judgements for inclusion for treatment parameters are ultimately left to the therapist. As further research is done many of the questions over inclusion or exclusion will, hopefully, be answered. 4.5 Recommendations to the Physiotherapist From the research performed several conclusions have been drawn. With consideration of these the physiotherapist can be advised to in the clinical confrontation of chronic pain. Recommendations for the clinical setting, such as treatment strategies and general recommendations are intended to make the therapist aware of advantageous treatment components. This set of recommendations does not necessarily have scientific support, though its inclusive into a treatment program would be beneficial. For example, a therapy that provides short-term relief of pain can increase the functional level for the duration of treatment. It would therefore not so scientific evidence for effectiveness in the long term, though its inclusion is advisable for immediate goals. Many of the conclusions regarding cost-effectiveness, facility requirements and patient receptiveness are based on prior knowledge and experience. They, categorically, are open to further research. Some evidence shows effectiveness in the short-term application; this means it is not proven for extended multiple uses through a treatment program. Rather, it is effective in instances. The following recommended treatment components are listed in order of suggested consideration. The order is derived from the evidence and research collected over the subject matter. While it is a point of contemporary debate, this list represents the opinions of the four reviewers. 4.5.1 Exercise Exercise therapy is overwhelmingly supported as the most effective method for the treatment of chronic pain. It lends itself so well to a graded activity approach to the activation of chronic pain patients. Exercise has demonstrated that it can have a significant lessening effect on a patients functional disability, and the frequency of pain occurrences. Time rather than their discomfort level should govern the patients resumption of normal activity. An intensive exercise program has been shown to be of more benefit than a light impact or low intensity program. Exercise programs also have the benefit of being cost effective. Functional exercise programs had the strongest evidence for their usage in chronic pain treatment. 4.5.2 Behavioral Therapy Evidence supports the addition of behavioral therapy to a physical therapy treatment plan for addressing chronic pain. Is it is commonly inserted in personal contact with the patient the cost effectiveness is greater in groups. Some specialty training courses are offered in this treatment method and some general knowledge would be advisable before implementation. 4.5.3 Relaxation Relaxation is useful for the reduction of anxiety, autonomic hyperactivity, and muscle tension, all of which are exhibited in the chronic pain state. Relaxation can have a positive affect on the impact of treatment. Techniques such as autogenic relaxation, meditation, progressive muscle relaxation, controlled breathing, or listening to relaxation tapes are commonly used in programs designed to manage chronic pain. There are approaches to relaxation that are mind-centered and others that are body-centered. Research is inconclusive for the effects of relaxation on long-term clinical out come, but that does not diminish the fact that relaxation is practical for the therapist and helpful for the patient. These methods are adaptable for use at home use as well as for use in other environments once the patient has learned the technique. 4.5.4 Biofeedback As discussed, is also lacking in scientific evidence for its effectiveness in chronic pain treatment. Though its effects on stress and relaxation would lend it to a valuable inclusion to a treatment program. It can be done in groups with little or no extra training required. It is further recommendable because it is not dependent on facilities or equipment. It is also well received by the patients. 4.5.5 Hydrotherapy There is lacking evidence to support the use of hydrotherapy in chronic pain intervention. As it can be implemented in a class setting, it can be cost effective. Though the initial investment and upkeep may be substantial. Some specific training in implementation of a program would also improve the effectiveness of the program. It has a reputation with patients of being very effective. Using a hydro environment allows the patient a variety of different sensations that can decrease the pain experience. Lessening the pain experienced will, ideally, enable the patient to participate in activities previously prohibited by the pain. There is a lack of evidence to support its use in chronic pain treatment, but can be justified by its short-term benefits. One logistical drawback to hydrotherapy is having a facility with a pool or suitable tank. 4.5.6 Manual therapy As with electrotherapy, manual therapy is scientifically supported in its short-term application for chronic pain. Although some systematic reviews have failed to find sufficient evidence to support or refute the use of manipulative physiotherapy in the treatment of chronic low back pain (Shekelle et al, 1992), therapists that use the technique find it practical. "Manipulation is more effective than a placebo treatment for chronic low back pain." There is moderate evidence that manipulation is more effective for chronic low back pain than standard care by the general practitioner, bed rest, analgesics and massage. At elemental levels there is not additional training needed. Though advanced techniques require some continued training. There are no restrictions as far as the facility is concerned and patients are generally receptive to it as an option. Manual therapy is an appropriate addition to the physical therapy treatment of chronic pain, but in a secondary position. There certainly are indications that manipulation might be effective in some subgroups of patients with low back pain. 4.5.7 Electrotherapy Although the use of Transcutaneous Electrical Nerve Stimulation (TENS) is not supported scientifically to have a lasting effect in the treatment of chronic pain, this modality continues to be widely used. Its value comes in short term usage to reduce the pain experienced by the patient in order to increase the functional ability in therapy. It does contain the risk of focusing the patient on the pain, or relying upon it to relieve their pain. The investment required for the investment in a unit is another down-fall of electrotherapy. This suggests that the benefits it provided, even if short lived, are desirable to patient and therapist alike. The affect of TENS on the perception of pain may prove to be a more valuable addition to any treatment plan. The potential for improvement, combined with reduced medication use and treatment costs, are important points that clinicians should consider when constructing a treatment plan for chronic pain patients. 4.5.8 Back school Educational programs in the intervention of low back pain have been shown to be effective. It would follow that a similar program for chronic pain would also create positive results. With class implementation the cost effectiveness is high, but evidence on comparative costs is still an opportunistic area. It is further easy to hold such a class in a variety of settings. There was no evidence supporting their use in chronic pain treatment though. Table 2. Therapy Recommendations Therapeutic InterventionScientifically supportedCost effectiveSpecialty training requiredFacility limitationsEquipment intensivePatient responsivenessExerciseStrong evidenceYesNoNoNoHighHydrotherapyLackingYes (in groups)YesPool requiredPool requiredHighRelaxationLackingYes (in groups)SomeNoNoHighBiofeedbackLackingYesNoNoNoHighBehavioral TherapyStrong evidenceYes (in groups)SomeNoNoHighManual TherapyFor short term onlyNoYesNoNoHighElectrotherapyFor short term onlyNoNoApplication unit requiredApplication unit requiredHighBack SchoolLacking for chronic painYes (in groups)NoNoPresentation materialUnknown 4.6 Recommendations for Further Research Chronic pain is an area that is at the forefront of contemporary physiotherapy debate. The direction of the field lies in the future of research and study. Chronic pain will remain a focal point for study, given its ellusive nature. Through the research numerous opportunities for further research arose. Some of the areas of research have specific well-localized needs for investigations, while others need more global inspection. Table 2. Recommendations of further researchArea of ReasearchInvestigation NeededGeneral Application of modern theory to practiceStudies to development more efficient modes of implementationTherapy for Chronic PainSpecific Exercise program effectivenessClinical studies to assess comparative effectiveness of exercise programs Rest v. ActivityExercise v. 2-3 days of rest on non-specific low back painManual therapyEffectiveness study to confirm or refute its use in chronic pain managementTENS in chronic painRandomized clinical trials to confirm or refute use in chronic pain treatmentFunctional RestorationResearch to determine measurements of restorationPsychological ApproachesResearch to determine which intervention is most effective on different patient groupsCognitive ApproachesComparative study of methods for effectiveness of interventionRelaxationClinical evidence to confirm or refute its efficacy in treating chronic painTraction, Massage and ModalitiesRandomized clinical trials to justify inclusion in therapy program for chronic painRelapse ManagementResearch to develop methods to maintain advances and prevent relapsePain Class (similar to Back School)Research and studies to determine effectiveness in chronic painPain Class (similar to Back School)Comparative cost effectiveness to non-participation in classAssessment toolsOvert Pain BehaviorUnilateral studies for Validity, Reliability, Utility, Sensitivity and ResponsivenessPain drawingUnilateral studies for Validity, ReliabilityNew Zealand GuidelinesUnilateral studies of specificity, sensitivity, utility, reliability, validityPain Disability IndexUnilateral studies of specificity, sensitivity, utilityVisual Analog ScaleUnilateral studies of specificity, sensitivity, utilityMultidimensional Pain InventoryUnilateral studies for Validity, Reliability, Utility, Sensitivity and Responsiveness PAGE 9 PAGE 16 Must size the heading accordingly EMBED SoundRec  PAGE \# "'Page: '#' '" Not necessary to write EVIDENCE here.  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