Physiotherapy for persistent pain

World Physiotherapy Day 8 September 2019

2019 Focus: Physiotherapy for Persistent Pain

Persistent (also often termed chronic) pain is now recognised as a disease of its own right [1]. This year’s World Physiotherapy Day focus is important as persistent pain affects quality of life; is shown to be a global contributor to the most expensive cost and days lived with disability [2]. Physiotherapy is a recognised profession to address the complexity of persistent pain with the holistic, specifically tailored approach to address the interaction of multiple factors [3]. The current model for the management of persistent pain applies a biopsychosocial approach [4] and the commonly practiced medical prescription of opioids is shown to be detrimental [5]. Indeed, the recognition of lifestyle factors to be integrated in a biopsychosocial approach places Physiotherapy in strong position to reduce the global burden of persistent pain.

The BIG question may be; If exercise or simply moving solved the problem of persistent pain, then why do we continue to have this overwhelming problem and that it is growing rather than shrinking? This is because, potentially, the problems of persistent pain may involve an interaction of any of these:

  • Reduced physical tolerance: which leads to other health problems.
  • Decline of mental health: which contributes to further disability or dependence.
  • Reinforcement of aberrant beliefs about pain: fear avoidance may persist.
  • Worsening of self-efficacy: subsequent erosion of self-confidence or dependence.
  • Sensitisation of central or peripheral mechanisms: poor response to usual treatment.
  • Failure of the brain’s downward modulation: the pain experience is recalcitrant.
  • Poor sleep: sleep hygiene and general health habits deteriorate.
  • Unhealthy eating habits: which also leads to other health problems.
  • Social withdrawal: aggravated by stigmatisation or co-dependence.
  • Negative reinforcement of the illness dependence role with reward associated compensation.

The GOOD news is what Physiotherapy can offer to resolve or at least reduce these problems.

Since exercise is indicated for ALL pain conditions; this means that getting the body moving correctly is beneficial for all the problems listed above.

  • Tolerance is essential to be factored so the prescribed exercise or activity is appropriate; enjoyed; easy to participate in and something that is looked forward to in a positive light every day.
  • An understanding of meaningful, mutual goal setting to empower the positive sense of accomplishment rather than what is ‘yet to be achieved’ or dependence. Referral for Psychological support can be made. 
  • Time taken to explain, reassure and educate about the thoughts and feelings that may be associated with the pain experience. These may inadvertently feed aberrant beliefs about pain and can be altered to healthier beliefs.
  • A structured approach with graded progressions facilitates self-efficacy and confidence.
  • Sensitisation problems can be assessed, accounted for in the exercise algorithm, and appropriate referral to a Medical Pain Physician can be made.
  • The brain’s ability to dampen a noxious stimulus appropriately is a beautiful, finely tuned mechanism which can be facilitated with Physiotherapy prescription of TENS, mindfulness, mirror reflected exercise, sensory motor training, the inhibition of primitive reflexes or relaxed breathing training in conjunction with the exercise.
  • Sleep problems can be assessed and education to improve sleep hygiene habits may help positively for improved sleep quality or duration. Referral for sleep clinics may be indicated. 
  • A programme to foster good eating habits that is not a ‘fad diet’ is readily available and can also be incorporated with the prescribed exercise. A common problem is the regular intake of high sugar, caffeine products that fuel the sensitisation processes or inhibit the downward modulation so the cycle of pain entrenches. 
  • Prescribed exercise that has a functional goal is essential so that it is not exercise for its own sake, but rather to accomplish, in a graded manner, social interaction for positive benefit. 
  • It may be difficult for some to recognise that injury compensation has facilitated positive reward to the illness dependent role. 

In summary: Contact your local Physiotherapist to help you with management of your persistent pain problem!

By Tracey Pons (Physiotherapy Specialist – Pain)


  1. Treede, R.D., et al., Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11). Pain, 2019. 160(1): p. 19-27.
  2. Vos, T., et al., Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet, 2015. 386(9995): p. 743-800.
  3. Nijs, J., et al., Lifestyle and Chronic Pain Across the Lifespan: An Inconvenient Truth? Pm r, 2019.
  4. Kamper, S.J., et al., Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. Cochrane Database of Systematic Reviews, 2014(9): p. 1-118.
  5. Wiss, D.A., A Biopsychosocial Overview of the Opioid Crisis: Considering Nutrition and Gastrointestinal Health. Front Public Health, 2019. 7: p. 193.

    Page updated September 2019