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Physical Therapy’s Role in Examining and Treating Chronic Pain Post Opioid Addiction: A Case ReportKathryn KroszkewiczCleveland State UniversityAbstractBackground and Purpose: Opioids are commonly used to treat chronic pain; however, this has become problematic due to the opioid crisis. Opioid abuse can result in addiction, Opioid Use Disorder, Opioid Induced Hyperalgesia, impaired quality of life, and death. Physical therapy (PT) is a viable option for long-term treatment of chronic pain both before opioid use and after addiction. The latter is scarcely mentioned in the literature and should be explored for a multitude of reasons. The purpose of this case report is to outline PT’s role in examining and managing chronic pain in an individual with a history of opioid drug addiction. Case Description: A 51-year-old female with 20 years of chronic low back pain and bilateral leg symptoms. Widespread body pain was also present and worsened with frequent life stressors. She had multiple comorbidities, negative health behaviors, poor health literacy, self-limiting beliefs, psychological factors and activity and participation restrictions. She has recently recovered from opioid addiction, but still suffers from debilitating pain. An examination revealed limited range of motion and leg strength, impaired balance and gait, and decreased cardiovascular endurance. She had 14 weeks of PT focusing on pain neuroscience education (PNE), aerobic exercise, therapeutic alliance, Swiss ball exercises, and dance therapy. Outcomes: The 6 Minute Walk Test, hip and lumbar mobility, and leg strength improved. There were significant improvements in motivation and subjective reports of activity and participation restrictions, however pain intensity continued to be related to life stressors. Discussion: Therapeutic alliance and interest specific exercises can positively impact the outcome. Barriers possibly limiting outcomes included life stressors impairing consistent improvement, poor adherence, no paralleled psychological interventions, and limited PNE. Manuscript word count: 3,479Background and PurposeChronic pain can be defined as pain lasting at least three months, or past the typical nociceptive signaling that something is physiologically wrong.1 Chronic pain is a major health crisis in the United States affecting millions.1,2 Many individuals may wait to seek treatment until the pain is chronic, which can be more challenging to improve.2 Opioid use is often the first line of defense with chronic pain.3,4 It is nationally known there is an opioid crisis due to the wide use of medication to manage pain.4 Of those prescription and illicit opioid users, the risk of addiction is high.4 The crisis is evident by the DSM-5 including Opioid Use Disorder in the list of recognizable psychological disorders.5 Compared to novice opioid users, those previous opioid users have an increase in long-term use.6 With long-term use of opioids studies show there can be Opioid Induced Hyperalgesia, or hypersensitivity to pain after drug use, further contributing to the chronic pain issue.7 Hyperalgesia stems from alterations in physiological pathways due to opioid abuse.4 Those who become addicted to drugs pose unique challenges to treatment when faced with chronic pain as a comorbidity.5 Treatment of pain is a human right, so if the solution to fighting chronic pain is through opioid use, no matter how low the drug dosage; then populations with a history of drug addiction are at a disadvantage when seeking treatment.1,4 Physical therapists (PT) are currently increasing public awareness that early PT is a viable alternative to opioids to fight the current crisis by decreasing pain, decreasing opioid initial and long-term use, and improving functional gains.3,8 Although the goal may be opioid crisis prevention, the crisis is underway and the next goal must be to target those on the other side facing addiction and chronic pain. PTs are qualified, now with a Doctor of Physical Therapy Degree, to be a part of the interdisciplinary team treating patients with multiple complex psychosocial comorbidities such as drug addiction.8 PT is the conservative, non-pharmacological, safe, and long-term answer to many individuals with chronic pain through individualize treatment plans.8 This topic is important to address for a multitude of reasons. Firstly, there is a high cost associated with the opioid crisis in terms of disability, death, economic impact, and social burden.2,4 Specifically, cost can be monetary within the healthcare system pre or post opioid use and work loss, or emotional with family burden, mental health impairments, and decreased quality of life.2 Secondly, a thorough evidence review revealed there is an urgent need for research due to the limited credible literature about non-pharmacological approaches, such as PT, in treating chronic pain in those with a history of opioid drug addiction. Thirdly, it is PT’s duty to become primary care providers to assist in addressing both the chronic pain and opioid crises. PT offers individuals the potential for recovery of the body and mind, as opposed to opioid’s offered illusion of recovery. The patient outlined in this case report embodies many of these aforementioned qualities. Therefore, the purpose of this case report is to outline PT’s role in examining and managing chronic pain in an individual with a history of opioid drug addiction. Case Description: Patient History and Systems ReviewThis report focuses on a 51-year-old American/Hispanic female with 20 years of chronic low back pain (LBP) with a significant increase in pain 4 years ago. She believes the pain is an accumulation of multiple motor vehicle accidents, dance and sport related injuries, and an equestrian related fall. Her chief complaint is debilitating LBP and left leg pain. The leg symptoms were described as weakness, numbness, pain, swelling, and the sensation of “legs being stuck in cement and can’t move.” Recent radiograph imaging revealed moderate narrowing of the left hip joint more so than the right hip, and degenerative changes of posterior elements of L3-S1. She has generalized whole body pain that worsens with stress. As outlined in Table 1. she has multiple comorbidities, negative health behaviors, psychological factors, and activity and participation restrictions. Her large body habitus concentrated around her abdomen limits her movement. She often becomes short of breath and dizzy with movement. Her long history of chronic pain, complicated social history, feeling of hopelessness led her to opioid use and addiction in 2017. Although she has recovered from her drug addiction, she still has many of the same stressors and feelings as before. Now she has the additional stressor of how to manage her pain with little to no opioid use. She is on a controlled low dose of Methadone to manage her addiction through the long-term withdrawal period. She is often self-limiting by choosing to perform sitting interventions, no supine, and limited standing exercises. She utilizes wheelchair transportation at the start of the therapy session but will ambulate out of the office pushing the wheelchair at the end of the session. She uses a straight cane for short ambulation due to pain with sustained walking. She reports being restricted in activities and participation roles, but the severity of the restriction varies with the number of stressors and thus pain present. She notes her psychological factors have an impact on her pain and is often tearful during therapy. She has attended counseling in the past with inconsistency. She believes something is horribly wrong with her health and has poor health literacy in understanding why she hurts. Her main goal with therapy is to reduce her daily amount of pain and activity and participation restrictions. Table 1. Co-Morbidities, Health Behaviors, Psychological Factors, Activity and Participation Restrictions, and Previous TreatmentCo-Morbidities Hepatitis C Carrier from Intravenous (IV) drug use Breast Cancer (diagnosed with Lobular Carcinoma April 29, 2019) Vertigo Prediabetes Body Mass Index (BMI) of 40 Bilateral Carpel Tunnel Syndrome Insomnia Sleep Apnea Frequent Urinary Tract Infections High CholesterolHealth Behaviors Smoker (1 pack a day) – Tobacco abuse IV Drug Addiction of Heroin and Methadone (March 2017 to March 2018) Alcohol Abuse COPD EmphysemaPsychological Factors Anxiety Depression Negative Outlook and Attitude Psychological Medications with Side EffectsActivity and Participation Restrictions Recently Homeless (living with mother at initial examination) Ex-Partner Raised Her Son (limited parenting) Limited Ability to Walk in the Community Unable to Dance Anymore General Activity Avoidance Limited Socialization Unable to Drive Limited Ability to Complete Activities of Daily Living (ADL) On Disability Previous Treatment Opioid Use Cervical Fusion of C4-5 and C 5-6 in 2000 Left Hip Cortisone Injections CounselingClinical Impression 1The first clinical impression after a thorough chart review is chronic LBP with radiating pain.9 This physical therapy diagnosis is consistent with her medical diagnosis of “LBP with unspecific laterality” (M54.5) and the APTA’s clinical practice guidelines for LBP.9 The pain is chronic with more than three months since onset and symptoms that travel into the leg.9 The recent imaging revealed posterior degenerative changes to the L3 through S1 region consistent with nerve root impingement that produces the pain felt mainly in the left leg. Activities involving extension are painful, which is also consistent with nerve root impingement due to spinal joint narrowing. The examination should include range of motion, special tests, motor and sensory testing, and outcome measures to establish where the pain is originating. Because this clinical impression precedes the physical examination, a list of differential diagnoses in Table 2. is beneficial to keep in mind when examining. Table 2. Differential Diagnosis ______________________________________________________________________________________________________________________________________________________Chronic LBP with related generalized painOpioid induced hyperalgesia Specific anatomic back or leg pathologyDeconditioning with generalized muscle hypertonicityPseudo or exaggerated symptoms to remain on disabilitySystematic condition warranting referral to physician Tumor/cancerExaminationThis patient had two examinations in December 2018 with the Back on TREK? Program and January 2019 with outpatient physical therapy both in the same department. Her orthopedic physician initially referred her to the program to target her chronic pain, which is the focus of the program consisting of pain neuroscience education (PNE), aerobic exercise, groups, and psychosocial interventions. She only attended one week of the eight-week program due to non-compliance and need for individualize attention. The results in Table 3. are from January’s outpatient examination. She used a wheelchair for long distances and a cane for short distances to compensate for poor balance, painful gait, and shortness of breath all of which needed a proper examination. Her posture was poor, evident by standing with a lordotic posture, frequent weight shifts and seated rest breaks due to pain. Figure 1. illustrates her pain locations that ranged from 5-10/10 pain, with 8/10 constant in the low back region. The pain sensation was described as burning, stabbing, and sharp indicating the type of tissue involved. She also declined to lie prone or supine on the mat during therapy due to pain once she stood up. She had general lumbar and hip hypomobility and pain especially with lumbar extension, left lateral flexion, left lumbar rotation, and hip external rotation. Mobility was tested to identify any specific areas of hypotonicity or directional preferences contributing to her pain. Both lower extremities were weak, but the most weakness was felt in left hip flexors and right ankle muscles. Similar patterns of diminished sensation were found. Sensation and strength testing are important to identify any myotomal or dermatomal distribution patterns that relate to low back vertebral segments. Bilateral reflexes were intact as well as upper motor neuron tests of Hoffman’s and Clonus were negative indicating reflexive mechanisms were intact. Of the special tests completed to test for hip pathology and dural tension, only bilateral FABER’s test and left straight leg raise were positive. Various outcome measures were used to objectively report her disability all of which showed impaired scores, however only the Oswesty Low Back Disability Questionnaire (ODI) was consistently recorded largely due to the patient’s unwillingness to complete the other measures.6 Table 3. Examination procedures, results, methods, and outcome measures______________________________________________________________________________________________________________________________________________________________________________________ Procedure Results Method 401814764040Visual inspection of resting sitting and standing posture when unaware of the assessment00Visual inspection of resting sitting and standing posture when unaware of the assessment178371584455 Rounded shoulders Increased lumbar lordosis Bilateral knee valgus Forward upper body Frequent weight shifting00 Rounded shoulders Increased lumbar lordosis Bilateral knee valgus Forward upper body Frequent weight shiftingPosture Sitting Standing_______________________________________________________________________________________________________________________________________________________405574588265Visual inspection ambulating around clinic00Visual inspection ambulating around clinic178371536195 Antalgic gait Bilateral Trendelenburg Single point cane00 Antalgic gait Bilateral Trendelenburg Single point caneGait _______________________________________________________________________________________________________________________________________________________18522952508252 seconds Left4 seconds RightSubjective report of frequent balance lossHistory of falls in the last year002 seconds Left4 seconds RightSubjective report of frequent balance lossHistory of falls in the last yearBalance Single leg stance406797183820Observed during examination Thorough history intake and subjective questioning00Observed during examination Thorough history intake and subjective questioning_____________________________________________________________________________________________________________________________________________________1906905396240Min limitation Mod limitation, painL Mod limitation, pain; R Min limitationL Mod limitation, pain; R Min limitationL normal; R normalL Mod limitation, pain; R Min limitationL Min limitation; R Min limitation00Min limitation Mod limitation, painL Mod limitation, pain; R Min limitationL Mod limitation, pain; R Min limitationL normal; R normalL Mod limitation, pain; R Min limitationL Min limitation; R Min limitation4170509408457Verbally guided through the different planes of movement and visually observed gross deviations 00Verbally guided through the different planes of movement and visually observed gross deviations Gross Active Range of Motion Lumbar Flexion Extension Lateral Flexion Rotation Hip Internal rotation External rotation Flexion _______________________________________________________________________________________________________________________________________________________Manual Muscle Test19151605381L 3+/5; R 4/5L 3/5; R 3+/5 L 4-/5; R 4/5L 4/5; R 4/5L 4/5; R 3+/5L 4+/5; R 4+/500L 3+/5; R 4/5L 3/5; R 3+/5 L 4-/5; R 4/5L 4/5; R 4/5L 4/5; R 3+/5L 4+/5; R 4+/54170566109637Standard Manual Muscle Test procedure 00Standard Manual Muscle Test procedure Hip Flexion Hip Extension Knee Flexion Knee Extension Ankle Dorsiflexion Ankle Plantarflexion 1923415445770L diminished; R intactL diminished; R intactL intact; R diminishedL intact; R intactL intact; R diminished00L diminished; R intactL diminished; R intactL intact; R diminishedL intact; R intactL intact; R diminished_______________________________________________________________________________________________________________________________________________________Sensation41703019175Light touch along the respective dermatomesLight touch along the respective dermatomes L2 L3 L4 L5 S1 _______________________________________________________________________________________________________________________________________________________1926590114300L Pos; R PosL Neg; R NegL Neg; R NegL Pos; R Neg00L Pos; R PosL Neg; R NegL Neg; R NegL Pos; R NegSpecial Tests FABER test Scour test FIDDER test Straight Leg Raise _______________________________________________________________________________________________________________________________________________________Outcome Measures December 2018 January 2019 April 2019 Lower Extremity Not Tested 16 Refused to participate Functional Scale Oswestry Low Back 50 52 60 Disability Questionnaire 6 Minute Walk Test 400 feet Not Tested 600 feet University of Alabama at Birmingham Pain Behavior 7.5 Not Tested 7.5 ScaleAbbreviations: L = Left, R = Right, Min = Minimal, Mod = Moderate, Pos = Positive, Neg = Negativeleft337185Figure 1. Pain Body Diagram______________________________________________________________________00Figure 1. Pain Body Diagram______________________________________________________________________Clinical Impression 2This patient does have examination findings consistent with chronic LBP with radiating pain and Practice Pattern 4C: Impaired Muscle Performance due to weakness, hypotonicity, and reduced activity performance.9,10 However, she has widespread pain throughout her body that consistently increases in intensity and locations with stressors. She has multiple biopsychosocial factors in her medical history, and maladaptive coping strategies evident by IV drug addiction. Therefore, she also has characteristics of chronic LBP with related generalized pain and potentially Opioid Induced Hyperalgesia.7,9 She would be a candidate for PNE, aerobic exercise, and specific lumbar, core, and hip exercise to address both of her physical therapy diagnoses over a 10 week period. InterventionAlthough the plan of care was initially set for 10 weeks, she completed 14 weeks of therapy. During that course of therapy various approaches to interventions were trialed and modified based on patient response. Discussed below are the interventions and timeline used in this case with specifics listed in Table 4. PNE was initially used formally as a part of the first week participating in the Back on TREK? Program. The education was guided by Why You Hurt: Pain Neuroscience Education System. This system included multiple lessons with flash cards offering illustrations to the patient and speaking points for the therapist. This form of education includes explaining why pain is present from a physiological standpoint, and a description of the innerworkings of the nervous system as to how it becomes hypersensitive.11 The education also outlines when pain is adaptive indicating a problem versus maladaptive pain no longer indicating a problem.11 Education about pain continued informally through the first weeks of individual therapy when the opportunity presented, however she never completed the formal multiple week program. This intervention has shown positive outcomes addressing widespread pain symptoms.11 The individual in this case was ideal for this intervention because of chronic maladaptive pain, poor coping strategies, ill perceptions of self, and a clinical presentation of pain hypersensitivity or widespread pain pattern worsened by stressors.11Aerobic exercise was the next intervention incorporated into her therapy sessions. This form of exercise is beneficial for chronic pain patients and those with hypersensitivity due to the hyperalgesia effects and recommendation in the LBP guidelines.9,12 Aerobic exercise facilitates increased blood flow, increased blood oxygen, decreases the number of trigger points, increases the pain threshold and releases endorphins as the body’s natural opioids.12 Similarly, a greater number of chronic musculoskeletal pain sites were linked to lower activity.13 Aside from the pain aspect, this individual was largely sedentary and would benefit from this intervention. She utilized wheelchairs whenever possible and spent most of her day sitting or lying. The NuStep machine was utilized at the beginning of every session gradually working up the rate and time exercised. A walking program was initiated and gradually increased using the Rate of Perceived Exertion. Walking was performed during therapy for reassessment, and education on a home walking routine with progression was frequently discussed. Also discussed were ways to increase daily activities to include more movement.Therapeutic exercises were used throughout the plan of care to treat the specific impairments found at the examination, and decrease pain with isometric strengthening.12 The LBP guidelines suggest therapeutic exercises and centralization exercises to reduce LBP.9 Specifically for LBP the exercises included core strengthening and flexion based exercise to be consistent with her directional preference.9 Exercises were employed to increase hip mobility and leg strength to improve pain and quality of movement. Various exercises completed in the clinic were suggested for home.Therapeutic alliance between patient and provider is important to establish with all patients. An article by Ferreira et al. discusses such alliance was a predictor for positive outcomes in those with chronic LBP.14 This one on one alliance was the reason the patient did not wish to continue with the group format of Back on TREK? as she desired individualized attention. For this case, the alliance was created through one consistent and compassionate therapist. The therapist spent time to quickly built rapport, demonstrate active listening, adjust the session based on the patient’s emotions, and develop her trust. Because of this relationship the therapist was in a position to provide information on improving health behaviors and referral to a psychological consult, to address recent lifestyle choices and psychosocial behaviors associated with her pain. Swiss ball exercises were introduced to improve balance and coordination, decrease pain, increase mobility, increase euphoric state, improve core and lower extremity strength. The patient expressed little interest in performing traditional exercises at week 9 but expressed interest in working with a swiss ball. Ball exercises are effective for improving lumbar stabilization, reducing chronic LBP, and increasing bone mineral density.14 Yoon et al. also found effectiveness of ball exercises by decreasing pain, decreasing anxiety, decreasing epinephrine, and increasing endorphin levels in perinatal mothers.15 The patient performed exercises on the ball both at the clinic and at home with increasing complexity.Although dance is not traditionally incorporated into therapy for pain, it was optimal for this patient based on her love for dance. The patient performed dance movements pulling from background of ballet and utilizing principles of core strengthening, mobility, lower extremity strengthening, and aerobic exercise. Only two sessions before the last incorporated dance to music, but she was extremely interested in her home program when focusing on dance. The idea of using dance as an intervention stemmed from the concept used in Functional Neurological Disorder where distractibility is key.17 Distraction when moving draws the focus away from the limited ability to move and pain, thus improving the movement without the individual realizing what is happening.17 Bidonde et al. explains the positive benefits of simple dance or formal dance movement therapy can have on persons with Fibromyalgia.18 Because her pain was often stressor dependent, dance is a way to target the mind and body by reducing stress while exercising and also being distracted. Table 4. Interventions________________________________________________________________________________________________________________________________________________________Time Frame Intervention Description 302577580010(Interventions varied from session to session depending on patient presentation. The following are general interventions) Education:Nervous system, types of pain, hypersensitivity, movement and pain, multiple interventions to reduce painGraded walking program starting at 400 feet daily with 3-5/10 RPENuStep 1 x week started at 3 minutes with 50 steps per minuteEducated about staying active daily and it’s benefitsSeated long arch quad (initially no weight, 2 sets of 8 reps)Seated hip abduction (yellow Theraband, 2 sets of 8 reps)Seated hip adduction (2 sets of 8 reps)Seated hamstring curls (yellow Theraband, 2 sets of 8 reps)Seated plantarflexion/dorsiflexion (2 sets of 8 reps)Seated marching (2 sets of 8 raps)Seated lumbar flexion stretch 3 x 10 second holdsDevelop rapport and trust with patientEducated on positive health behaviors (stop smoking, decrease alcohol abuse, sleep hygiene, lose weight, improve diet, decrease risky behaviors) Educate on positive lifestyle choicesIncorporate interventions to decrease anxiety and depression_________________________________________AerobicTherapeutic Exercises Therapeutic AllianceSwiss Ball ExercisesDance00(Interventions varied from session to session depending on patient presentation. The following are general interventions) Education:Nervous system, types of pain, hypersensitivity, movement and pain, multiple interventions to reduce painGraded walking program starting at 400 feet daily with 3-5/10 RPENuStep 1 x week started at 3 minutes with 50 steps per minuteEducated about staying active daily and it’s benefitsSeated long arch quad (initially no weight, 2 sets of 8 reps)Seated hip abduction (yellow Theraband, 2 sets of 8 reps)Seated hip adduction (2 sets of 8 reps)Seated hamstring curls (yellow Theraband, 2 sets of 8 reps)Seated plantarflexion/dorsiflexion (2 sets of 8 reps)Seated marching (2 sets of 8 raps)Seated lumbar flexion stretch 3 x 10 second holdsDevelop rapport and trust with patientEducated on positive health behaviors (stop smoking, decrease alcohol abuse, sleep hygiene, lose weight, improve diet, decrease risky behaviors) Educate on positive lifestyle choicesIncorporate interventions to decrease anxiety and depression_________________________________________AerobicTherapeutic Exercises Therapeutic AllianceSwiss Ball ExercisesDance1026795189230Pain Neuroscience EducationAerobic ExerciseTherapeutic Exercises Therapeutic Alliance 00Pain Neuroscience EducationAerobic ExerciseTherapeutic Exercises Therapeutic Alliance Initial -64770287361_________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________-----__________________00_________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________-----__________________308038561595Graded walking program starting at 500 feet daily with 5/10 RPENuStep 1 x week started at 8-10 minutes with 65 steps per minuteSeated long arch quad (3 pound cuff weight, 3 sets of 8 reps)Seated hip abduction (green Theraband, 3 sets of 8 reps)Seated hip adduction (2 sets of 8 reps)Seated hamstring curls (green Theraband, 3 sets of 8 reps)Seated plantarflexion/dorsiflexion (3 sets of 8 reps)Seated marching (3 sets of 8 raps)Seated lumbar flexion stretch (3 x 10 second holds)Transitioned to:Standing hip abduction (no weights, 2 sets of 10 reps)Standing hip extension (no weights, 2 sets of 10 reps)Standing marching (2 sets of 10 reps)Standing dorsiflexion/plantarflexion (2 sets of 10 reps)Mini squat with upper extremity support (5 reps)3 direction ball rollout lumbar stretch (10 x 10 second holds)Referred for psych consultContinued to discuss and provide education:Develop rapport and trust with patientEducate on positive health behaviors (stop smoking, decrease alcohol abuse, sleep hygiene, lose weight, improve diet, decrease risky behaviors) Educate on positive lifestyle choicesIncorporate interventions to decrease anxiety and depressionGraded walking program starting at 600 feet daily with 5-6/10 RPENuStep 1 x week started at 15-20 minutes with 80 steps per minuteReeducated about staying active daily and it’s benefitsSeated external and internal rotation (yellow Theraband, 2 sets of 10 sets)Seated reaching with medicine ball (2 sets of 8 reps)Standing hip abduction (2 pound weights, 3 sets of 10 reps)Standing hip extension (1 pound weights, 3 sets of 10 reps)Standing marching (2 pounds weights, 3 sets of 10 reps)Standing dorsiflexion/plantarflexion (2 pound weight, 3 sets of 10 reps)Mini squat with upper extremity support (2 set of 10 reps)Lateral walking (yellow Theraband, 5 x 15 feet)3 direction ball rollout lumbar stretch (10 x 10 second holds)Standing marching on foam (2 pounds weights, 3 sets of 10 reps)Single leg stance with upper extremity support 5 secondsContinued to recommend psych consult Continued to discuss and provide education:Develop rapport and trust with patientEducate on positive health behaviors (stop smoking, decrease alcohol abuse, sleep hygiene, lose weight, improve diet, decrease risky behaviors) Educate on positive lifestyle choicesIncorporate interventions to decrease anxiety and depressionStanding:Single leg march with contralateral elbow touching kneeSquat with hip external rotation and arm eccentrically adductingWeight shift with trunk rotation and contralateral arm abductionLateral stepping following a left right left patternArms towards and away from the chest with opposite anterior and posterior pelvic tiltIpsilateral hip and arm extension Semi tandem stance with arm movementBouncing - sensory input and core control Anterior/Posterior pelvic tiltPelvic rotationSeated paloff pressSeated marching with 3 second holdsSeated reaching and circles with 2 pound medicine ballSeated dead bug with second swiss ball00Graded walking program starting at 500 feet daily with 5/10 RPENuStep 1 x week started at 8-10 minutes with 65 steps per minuteSeated long arch quad (3 pound cuff weight, 3 sets of 8 reps)Seated hip abduction (green Theraband, 3 sets of 8 reps)Seated hip adduction (2 sets of 8 reps)Seated hamstring curls (green Theraband, 3 sets of 8 reps)Seated plantarflexion/dorsiflexion (3 sets of 8 reps)Seated marching (3 sets of 8 raps)Seated lumbar flexion stretch (3 x 10 second holds)Transitioned to:Standing hip abduction (no weights, 2 sets of 10 reps)Standing hip extension (no weights, 2 sets of 10 reps)Standing marching (2 sets of 10 reps)Standing dorsiflexion/plantarflexion (2 sets of 10 reps)Mini squat with upper extremity support (5 reps)3 direction ball rollout lumbar stretch (10 x 10 second holds)Referred for psych consultContinued to discuss and provide education:Develop rapport and trust with patientEducate on positive health behaviors (stop smoking, decrease alcohol abuse, sleep hygiene, lose weight, improve diet, decrease risky behaviors) Educate on positive lifestyle choicesIncorporate interventions to decrease anxiety and depressionGraded walking program starting at 600 feet daily with 5-6/10 RPENuStep 1 x week started at 15-20 minutes with 80 steps per minuteReeducated about staying active daily and it’s benefitsSeated external and internal rotation (yellow Theraband, 2 sets of 10 sets)Seated reaching with medicine ball (2 sets of 8 reps)Standing hip abduction (2 pound weights, 3 sets of 10 reps)Standing hip extension (1 pound weights, 3 sets of 10 reps)Standing marching (2 pounds weights, 3 sets of 10 reps)Standing dorsiflexion/plantarflexion (2 pound weight, 3 sets of 10 reps)Mini squat with upper extremity support (2 set of 10 reps)Lateral walking (yellow Theraband, 5 x 15 feet)3 direction ball rollout lumbar stretch (10 x 10 second holds)Standing marching on foam (2 pounds weights, 3 sets of 10 reps)Single leg stance with upper extremity support 5 secondsContinued to recommend psych consult Continued to discuss and provide education:Develop rapport and trust with patientEducate on positive health behaviors (stop smoking, decrease alcohol abuse, sleep hygiene, lose weight, improve diet, decrease risky behaviors) Educate on positive lifestyle choicesIncorporate interventions to decrease anxiety and depressionStanding:Single leg march with contralateral elbow touching kneeSquat with hip external rotation and arm eccentrically adductingWeight shift with trunk rotation and contralateral arm abductionLateral stepping following a left right left patternArms towards and away from the chest with opposite anterior and posterior pelvic tiltIpsilateral hip and arm extension Semi tandem stance with arm movementBouncing - sensory input and core control Anterior/Posterior pelvic tiltPelvic rotationSeated paloff pressSeated marching with 3 second holdsSeated reaching and circles with 2 pound medicine ballSeated dead bug with second swiss ball104711547625Aerobic ExerciseTherapeutic Exercises Therapeutic AllianceAerobic ExerciseTherapeutic Exercises Therapeutic AllianceDanceSwiss Ball Exercises00Aerobic ExerciseTherapeutic Exercises Therapeutic AllianceAerobic ExerciseTherapeutic Exercises Therapeutic AllianceDanceSwiss Ball Exercises6 week -65300243868_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________00_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________10 week RPE = Rate of Perceived Exertion OutcomesThe stressor-pain relationship noted throughout the case report dramatically altered her presentation session to session. She had limited ability to cope and poor compliance with her home exercise program requiring many modifications and a slow progression of interventions. Because of this inconsistency, subjective measures instead of objective measures captured the essence of her improvement. The only exceptions were noted improvements on objective measures of the 6 Minute Walk Test (6MWT), strength, and mobility. She improved her 6MWT by 200 feet, which is considered a Minimally Clinically Important Difference and a Minimal Detectable Change for older adults.19 During the 6MWT she also required less use of her cane and less shortness of breath evident by her ability to carry on a conversation while walking. The 6MWT has excellent reliability and adequate validity.19 Her lower extremity strength improved to ≥ 4/5 in the impaired myotomes. There was also improvement in lumbar and hip mobility with only minimal deficiency in problem areas and slight lingering pain with lumbar extension and left side bend. Overall during the final four sessions she expressed subjective report of satisfaction with therapy. She was starting to have more good days with decreased pain, increased physical activity, improved sleep, improved health behaviors, and improved quality of life. She reportedly reduced the amount of time during the day she was debilitated by her pain. Initially she had almost a full day of debilitating pain, but now only part of the day was debilitating. Her activity and participation roles listed in Table 5. improved as well. She was living independently with ability to perform ADLs and had reestablished contact with her son. She began participating again by volunteering at homeless shelters for socialization and giving back to the community. She was able to rescue and care for a little dog that became her best friend and an excellent source of stress relief. She frequently discussed her dog and mentioned how he saves her from pain on days when stressors are present. She also started walking short distances with her dog and noted losing weight. Although stressors and pain were still linked, PT helped her understand the relationship and various ways to cope. She insisted on having therapy Monday mornings to start her week off with motivation. Therapy gave her confidence to start exercising again. She was motivated by her ability to perform basic dance movements that were introduced in therapy. She noted when exercising or after therapy sessions she felt better and was in a better place mentally. These outcomes reflect up until the last visit when therapy was abruptly paused until cancer treatment was established. Table 5. Improvements in Activity and Participation - International Classification of Function, Disability and Health (ICF) Improvement in Restrictions Initial Examination After 14 Therapy Sessions ______________________________________________________________________________________________________________________________________________________________________________________156654571755-Living with Mother-Limited Contact with Son -Limited Ability to Walk in the Community-Unable to Dance Anymore-General Activity Avoidance-Unable to Drive-Limited Ability to Complete ADLs-Limited Socialization00-Living with Mother-Limited Contact with Son -Limited Ability to Walk in the Community-Unable to Dance Anymore-General Activity Avoidance-Unable to Drive-Limited Ability to Complete ADLs-Limited Socialization387921571755-Living Independently-Visits Son Frequently-Ability to Walk 600 feet in 6MWT-Motivated to Start Basic Dancing-Increased Physical Activities -Hired a Driver-Completing ADLs-Volunteer at Homeless Shelter -Pet Owner00-Living Independently-Visits Son Frequently-Ability to Walk 600 feet in 6MWT-Motivated to Start Basic Dancing-Increased Physical Activities -Hired a Driver-Completing ADLs-Volunteer at Homeless Shelter -Pet OwnerActivity and Participation DiscussionThe purpose of this case report was to present how PT impacted an individual with chronic pain and recent history of opioid drug addiction. This individual had 14 weeks of PT focusing on PNE, aerobic exercise, therapeutic alliance, Swiss ball exercises, and dance therapy. All these interventions are supported in the literature for use with chronic pain, however there is limited research for use with drug addiction. There was even less research on PTs treating chronic pain in persons with previous drug addiction, therefore this case report attempts to bridge this gap. Treating pain with drug addiction is more complex than solely treating chronic pain. In drug addiction, opioid induced hyperalgesia can develop where there is enhanced signaling in the spinal cord.7 This response is especially present during the withdrawal period, and is similar to the individual who perceives non-painful stimuli as painful.7,20 Attempts to combat this pain are generally treated with low controlled doses of methadone, which can be counterproductive in some still struggling with addiction.7,20 This is where PT can provide a safer alternative to treat pain.8,20 Another side effect of previous opioid abuse is neuroticism and anxiety.21 The individual in this case improved overall but was still significantly limited on bad days. Objective outcome measures of self-report might be used with caution in this population and those with limited health literacy based on the patient’s worsened final ODI score. There were barriers identified possibly limiting greater improvement. The patient had poor compliance with performing home exercises and making health behavior modifications. Often the only exercise completed in a week was during therapy indicating poor motivation and dependency. Poor adherence to PT is linked to poor outcomes.22 Such poor adherence is found in little previous activity, low self-efficacy, depression, anxiety, helplessness, poor support, more noted barriers, and perceived increase in pain during exercise.22 Strategies to overcome this and develop long-term relief include keeping therapeutic alliance, create self-management goals, develop intervention based off patient preference, and reduce triggers causing pain.23 The main lasting issue in this case was increased pain with stressors. When stressors are evoked cortisol is facilitated, however in maladaptive perception of stressors there is an exacerbated cortisol release contributing to fear and pain memories.24 PTs recognizing exaggerated stressors in patients with pain should consider screening for a link through perceived stress scales.24 Stress responses are further altered in the drug addicted population with increased anxiety, neuroticism, and ill self-perception.21 Although interventions for both likely diagnoses of chronic LBP with radiating and generalized pain were addressed, three specific areas for improvement can be discussed. PNE used was mostly informal and did not follow the established multiple week program. Although PNE can be beneficial not every PT performs it correctly due to limited knowledge of clinical application.25 If PNE is not completed in entirety the desired outcomes could suffer. Only formal PNE was offered in the Back on TREK? program, however completion of the multiple week formal PNE program might have been beneficial in individual therapy. Due to the link between stressors, psychosocial factors and pain, the patient might have benefited from a psychological intervention such as stress management or cognitive behavioral therapy.24 The idea was frequently discussed, however the patient always had a reason why she could not pursue that option. More frequent use of patient preference for interventions could have been utilized, such as dance, to increase compliance and target physical and mental aspects of pain by reducing stress and providing distraction.17,18,23 Even though dance was only incorporated into two sessions, the patient for the first time asked how they could dance at home for exercise. In future research there is a need to examine how PTs can treat a previous drug addicted population with pain, and how it differs from treating regular chronic pain.References1. Treede RD, Rief W, Barke A, et al. A classification of chronic pain for ICD-11. Pain. 2015;156(6):1003–1007. 2. Due?as M, Ojeda B, Salazar A, Mico JA, Failde I. A review of chronic pain impact on patients, their social environment and the health care system. J Pain Res. 2016;9:457-467.3. Sun E, Moshfegh J, Rishel CA, Cook CE, Goode AP, George SZ. Association of Early Physical Therapy With Long-term Opioid Use Among Opioid-Na?ve Patients With Musculoskeletal Pain. JAMA Netw Open. 2018;1(8).4. Bart G. Maintenance medication for opiate addiction: the foundation of recovery. J Addict Dis. 2012;31(3):207–225. 5. Wachholtz A, Foster S, Cheatle M. Psychophysiology of pain and opioid use: implications for managing pain in patients with an opioid use disorder. Drug Alcohol Depend. 2015;146:1–6. 6. DiMarco LA, Ramger BC, Cook CE, et al. Differences in Characteristics and Downstream Drug Use Among Opioid-Na?ve and Prior Opioid Users with Low Back Pain. Pain Pract. 2019;19(2):149-157.7. Martin?S. Angst, J?David Clark; Opioid-induced Hyperalgesia: A Qualitative Systematic Review. Anesthesiology 2006;104(3):570-587.8. Hayhurst C. MOVING AWAY FROM OPIOID RELIANCE: An APTA white paper analyzes the opioid crisis and outlines how physical therapy can contribute to the solution. PT in Motion. 2018;(9):32-44. . Accessed May 1, 2019. 9. Delitto A, George SZ, Van Dillen L, et al. Low back pain. J Orthop Sports Phys Ther. 2012;42(4):A1–A57. doi:10.2519/jospt.2012.42.4.A110. Adapted Practice Patterns. Alexandria, VA: American Physical Therapy Association;2015. Available at: . Accessed May 31, 2019.11. Nijs J, van Wilgen CP, Van Oosterwijck J, van Ittersum M, Meeus M. How to explain central sensitization to patients with “unexplained” chronic musculoskeletal pain: Practice guidelines. Man Ther. 2011;16(5):413-418.12. Ahmed S, Khattab S, Haddad C, Babineau J, Furlan A, Kumbhare D. Effect of aerobic exercise in the treatment of myofascial pain: a systematic review. J Exerc Rehabil. 2018;14(6):902–910. 13. Murata S, Doi T, Sawa R, et al. Association Between Objectively Measured Physical Activity and the Number of Chronic Musculoskeletal Pain Sites in Community-Dwelling Older Adults. Pain Med. 2019;20(4):717-723.14. Ferreira PH, Ferreira ML, Maher CG, Refshauge KM, Latimer J, Adams RD. The Therapeutic Alliance Between Clinicians and Patients Predicts Outcome in Chronic Low Back Pain. Phys Ther. 2013;93(4):470-478.15. Yoon JS, Lee JH, Kim JS. The Effect of Swiss Ball Stabilization Exercise on Pain and Bone Mineral Density of Patients with Chronic Low Back Pain. J Phys Ther Sci. 2013;25(8):953-956.16. Henrique AJ, Gabrielloni MC, Rodney P, Barbieri M. Non-pharmacological interventions during childbirth for pain relief, anxiety, and neuroendocrine stress parameters: A randomized controlled trial. Int J Nurs Pract. 2018;24(3):e12642.17. Stone J. Functional neurological disorders: The neurological assessment as treatment. Clin Neurophysiol. 2014;44(4):363-373.18. Bidonde J, Boden C, Busch AJ, Goes SM, Kim S, Knight E. Dance for Adults With Fibromyalgia-What Do We Know About It? Protocol for a Scoping Review. JMIR Res Protoc. 2017;6(2):e25. 19. Ability Lab. 6 Minute Walk Test. Available at: . Accessed June 12, 2019.20. Savage SR, Kirsh KL, Passik SD. Challenges in using opioids to treat pain in persons with substance use disorders. Addict Sci Clin Pract. 2008;4(2):4–25.21. Koh CH. Neuroticism Is Associated with Chronic Severe Pain among Ex-Opioid Users in Methadone Maintenance Therapy. Int Med J. 2019;(1):15.22. Jack K, McLean SM, Moffett JK, Gardiner E. Barriers to treatment adherence in physiotherapy outpatient clinics: a systematic review. Man Ther. 2010;15(3):220–228.23. Beattie PF. Silfies SP. Improving long-term outcomes for chronic low back pain: time for a new paradigm? J Orthop Sports Phys Ther. 2015;45(4):236-239.24. Hannibal KE, Bishop MD. Chronic stress, cortisol dysfunction, and pain: a psychoneuroendocrine rationale for stress management in pain rehabilitation. Phys Ther. 2014;94(12):1816–1825.25. Louw A, Puentedura EJ, Zimney K, Schmidt S. Know Pain, Know Gain? A Perspective on Pain Neuroscience Education in Physical Therapy. J Orthop Sports Phys Ther. 2016;46(3):131-134. ................
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