Acute pain has a purpose, chronic pain, not so much.

People feel pain when the brain receives a signal that a disease or injury threatens their well-being. The brain signals a worker that they’ve hurt their back, so they quit doing what caused it and seek relief. With chronic pain, the brain interprets a signal as a threat when there is none.

Physical therapy is the go-to for musculoskeletal injuries and the acute pain they bring. The sooner therapy starts, the better. But what about pain that has gone on for three months or three years? Can physical therapy still help?

Pain is one of the most common reasons that people seek medical care. Severe chronic pain negatively affects physical and mental functioning and diminishes quality of life. It also creates a financial burden for individuals and employers. “Relieving Pain in America,” published by the Institute of Medicine of the National Academies, puts the cost of chronic pain between $560-630 billion a year.

More than 116 million adults in the US suffer from chronic pain, and it seems to affect workers’ comp patients even more than the general population. This is according to a study published in Relational Behavioral Medicine that found that workers’ compensation patients were “generally more distressed and had poorer outcomes than those not covered by workers’ comp.”

Pain is typically considered chronic when it has continued for three to six months. Chronic pain can become a condition unto itself, posing a major barrier to return to work. It can cause anxiety, irritability, and depression, and it is complex and difficult to treat.

Yet injured workers who have chronic pain–even those who have been in pain for years–can benefit from physical therapy.

The main difference in the therapeutic approach for acute versus chronic pain is the balance between education and exercise. When there is a recent injury, therapists focus more on exercise and manual therapy to restore strength and mobility and get the patient out of pain.

Education plays a role in treating acute pain, but it takes center stage when treating chronic pain. Understanding the mechanisms of pain, especially how chronic pain develops, helps patients identify ways to derail it.

When pain goes on a long time, the body develops workarounds for coping. The person’s posture changes, and they may slump or limp. Muscles tighten, trigger points develop, and stiffness deconditioning can occur. Some patients do not feel like moving around, and their lack of activity decreases circulation, weakens muscles, and can affect joint mobility.

These injured workers need more education about the mechanisms of pain, how to relieve it, how move more efficiently, and ideally, how to self-manage it. It’s good to have patients start with a consultation with a physical therapist to discuss the injury, their pain experience, and how it has affected their lives and ability to work. Patients should understand that this course of physical therapy will differ from treatment they had immediately post injury.

This session should include a psychosocial screening even if the worker was screened earlier. Psychosocial factors often develop as pain continues. Some patients come to believe that they’ll always be in pain, never be able to do what they once did, and they lose hope.

Treatment needs to be patient-centric and customized. Combining aerobic conditioning with strength training helps some people, while relaxation and mindfulness work better for others.

Shared decision-making is important. According to an article in the Journal of Manual and Manipulative Therapy, the traditional decision-making process where the provider is the authority and the patient does what they’re told, doesn’t cut it. Collaboration is key.

The therapist will demonstrate strength, mobility and flexibility exercises and apply manual therapy, such as trigger point and myofascial release, spinal manipulation, and dry needling, and explain how they work and their benefits. The patient gives feedback on which techniques help. Together, the patient and therapist decide on the treatment program and set realistic expectations for eliminating or managing pain.

Chronic pain patients learn how their bodies have created workarounds to accommodate injuries and how they led to pain. They see that adjusting their posture or doing a particular set of stretches brings relief. As patients learn the reasons that certain exercises and stretches help them feel better, they become more likely to comply with the exercise program.

There are encouraging success stories of chronic pain patients who have tapered off high doses of opioids and overcome chronic pain through physical therapy. Others learn to accept a level of pain and how to reduce its frequency and intensity. Unfortunately, not every injured worker attains 100-percent freedom from pain.

Consider examining your portfolio of claims for workers in chronic pain and suggest a course of physical therapy. Things change as time goes on, and injured workers who couldn’t accept that they might always have pain may be ready to learn how to manage it.

Ideally workers’ compensation professionals and practitioners will learn to intercept pain before it becomes chronic. Stay tuned for more on this in part 2 of the series!