Many of the patients I work with often tell me they came in to see me because they were told the pain they feel is all in their head. Wow! I am always blown away at how shaming this kind of message is for people in pain. What they hear, and what the unknowing healthcare provider often means, is that there isn't a physical reason for the pain they are reporting. Technically, pain signals are processed in the brain, but there are many more questions about the origins of chronic pain than we have answers for. But pain is pain, and I believe it is important for my patient's recovery to accept their report of pain as valid. It is also important for them to develop a better understanding of how the pain system works and its impact on their chronic pain management program so a good part of my work with them is education.

On October 16, 2010 I posted a blog titled The Role of Neuroplasticity in Chronic Pain Management. Neuroplasticity is defined as: The brain's ability to reorganize itself by forming new neural connections throughout life. Neuroplasticity allows the neurons (nerve cells) in the brain to compensate for injury and disease and to adjust their activities in response to new situations or to changes in their environment. This information ties in to my current focus.

We know that many people living with chronic pain experience different types of memory problems. But as I was conducting research on this month's News/Research post I ran across an interesting article about memory and chronic pain with the premise being "memory that shouldn't be made" is causing the problem. Excerpts of that news release are below. The entire article can be found at Newswise.

Chronic pain is an epidemic. One in four Americans suffers from chronic pain due to disease—including cancer and HIV—and the medications used to treat those diseases. One reason for the persistence of chronic pain may be that the patient's central nervous system creates abnormal connections or improves connections that shouldn't be strengthened, explains Susan G. Dorsey, PhD, RN, co-director of the School of Nursing's Center of Excellence in Disorders of Neuroregulatory Function.

"Chronic pain makes a memory that shouldn't be made, such as the lasting damage to peripheral nerves sometimes caused by cancer drugs," she says. "The pain can still last after cancer treatment stops, and once memories are formed, they are difficult to unlearn."

Exploring why the central nervous system creates improper connections is a simple definition of the Center's complex, cutting-edge research conducted by Dorsey, co-director Christopher Ward, PhD, and their team of faculty and student investigators, who study the molecular, cellular, and genetic mechanisms underlying the development and persistence of chronic pain. "We study the nervous system and diseases of muscles and how the nervous system regulates muscle function," explains Dorsey, who received both her MS and PhD from the School of Nursing and was a critical care/ICU nurse before earning her PhD in nursing/neuroscience.

I believe that changing the way the brain interprets pain is crucial. This led me to looking at how and why hypnosis or self hypnosis has been such an important element of my own personal chronic pain management, as well as for many of my patients. One internet site I find helpful is WebMD where I found information about the effectiveness of hypnosis in an interesting article titled Hypnosis, Meditation, and Relaxation for Pain Treatment. You can read the entire article at WebMD.

Stress and pain are intimately related. When being in pain causes stress or being stressed worsens pain, psychological therapies – including hypnosis, meditation, and relaxation – may help break the cycle. For pain therapists, these treatments, which focus on the relationship between the mind and body, are considered mainstream. For other health professionals, they may be considered alternative or complementary therapies. Regardless of how they are labeled, there is evidence that for many people they work.

For many, the word hypnotize brings to mind a parlor game or nightclub act, where a man with a swinging watch gets volunteers to walk like a chicken or bark like a dog. But clinical, or medical hypnosis, is more than fun and games. It is an altered state of awareness used by licensed therapists to treat psychological or physical problems.

During hypnosis, the conscious part of the brain is temporarily tuned out as the person focuses on relaxation and lets go of distracting thoughts. The American Society of Clinical Hypnotists likens hypnosis to using a magnifying glass to focus the rays of the sun and make them more powerful. When our minds are concentrated and focused, we are able to use them more powerfully. When hypnotized, a person may experience physiologic changes such as a slowing of the pulse and respiration, and an increase in alpha brain waves. The person may also become more open to specific suggestions and goals such as reducing pain. In the post-suggestion phase, the therapist reinforces continued use of the new behavior.

Research has shown medical hypnosis to be helpful for acute and chronic pain. In 1996, a panel of the National Institutes of Health found hypnosis to be effective in easing cancer pain. More recent studies have demonstrated its effectiveness for pain related to burns, cancer, and rheumatoid arthritis and reduction of anxiety associated with surgery. An analysis of 18 studies by researchers at Mount Sinai School of Medicine in New York revealed moderate to large pain-relieving effects from hypnosis, supporting the effectiveness of hypnotic techniques for pain management.

Since fibromyalgia has had a difficult time gaining acknowledgement from the greater medical community I wanted to do an update on this common chronic pain management problem since last month was National Fibromyalgia Awareness month. The National Fibromyalgia Association (NFA) is a great resource for both patients and healthcare providers who want to increases their understanding of this condition. On their website (http://www.fmaware.org/ ) you can find fibromyalgia support groups, chat rooms and stories of real people living with this disease.

The Mayo Clinic defines fibromyalgia as a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues. Researchers believe that fibromyalgia amplifies painful sensations by affecting the way your brain processes pain signals. Symptoms of fibromyalgia sometimes begin after a physical trauma, surgery, infection or significant psychological stress. In other cases, symptoms gradually accumulate over time with no single triggering event.

Just how great a problem is fibromyalgia? It is considered to be the most common cause of chronic widespread pain and affects approximately 6 million Americans. In studies throughout the world, fibromyalgia is found in between three to four percent of the population and is three to eight times more common in females. In outpatient rheumatology care, it is the second most prevalent musculoskeletal disorder, after osteoarthritis.

Because fibromyalgia is so commonly misdiagnosed and because its causes are not understood fully, it is difficult to effectively determine its risk factors. However, a few are known. As mentioned above it is much more common in women. The most common age to be diagnosed with fibromyalgia is early to middle adulthood—between 20 and 50 years old. If you have a close relative with fibromyalgia, you are more likely to be diagnosed yourself.

The lack of understanding of what causes fibromyalgia and how it manifests has made this condition frustrating for patients and their healthcare providers. A recent public awareness survey by the National Fibromyalgia Association illustrates a significant lack of understanding about fibromyalgia: nearly half of the general public (45%) has never heard of fibromyalgia, many people who are knowledgeable about the disorder incorrectly believe that nothing can be done to manage it, and nearly half (48%) of all healthcare providers are reluctant to diagnose a patient with the condition (From the National Fibromyalgia Association, 2007 Report). Not much has changed in four years.

Once people are diagnosed with this condition the problem continues. What is the best treatment? There are many different points of view here and many of them are dictated by the healthcare professionals orientation, discipline, and understanding of this condition. I like many realize it takes a multidisciplinary approach to obtain positive treatment outcomes.

As I was searching on Medscape.com I found an interesting continuing education activity titled Fibromyalgia Multidisciplinary Expert Column Series: Advancing Multidisciplinary Disease Management Strategies in Fibromyalgia, and have posted excerpts below. To read the entire post you will need to sign up for the free Medscape.com membership, then search for this activity by title.

In the United States, the majority of patients with fibromyalgia are diagnosed and treated by primary care physicians. Approximately 15% of patients are under the care of specialists, usually rheumatologists. The large number of patients with fibromyalgia requires that primary care physicians take care of the majority of patients with this common illness. However, primary care physicians may not be comfortable in making a timely diagnosis of this disorder. Patients with fibromyalgia average 3-5 years of symptoms before a diagnosis is made.

Initial Disease Management

Therefore, it is important that primary care clinicians are knowledgeable about fibromyalgia so they can make an earlier diagnosis and initiate therapy quickly. It is hoped that, in the near future, they become as comfortable with the diagnosis and initial therapy of fibromyalgia as they are currently with that of migraine or depression.

[In an optimal model] the primary care physician, along with non-physician healthcare providers, directs the initial management program. Each patient's symptoms should be evaluated, and therapy needs to be individualized. Those patients who have more psychosocial factors impacting on their symptoms would benefit from earlier mental health evaluation and consideration of techniques such as cognitive behavioral therapy.

The level of physical fitness and individual barriers to achieving physical fitness should be evaluated. Many patients will benefit from structured physical therapy and exercise advice, at least initially. Some will also benefit from an occupational therapy evaluation, especially with regard to work-related symptoms.

Pharmacologic management should be initiated with a single drug, mono-therapy, based on evidence-based recommendations. Currently in the United States, pregabalin, duloxetine, and milnacipran are approved by the Food and Drug Administration for the treatment of fibromyalgia. The recommended doses are 300-450 mg/day of pregabalin, 60 mg/day of duloxetine, and 100-200 mg/day of milnacipran.

Tricyclic antidepressants, including amitriptyline and cyclobenzaprine, have demonstrated improvement compared with placebo and are used typically in low doses, such as 20-30 mg, and only at night-time. The only analgesic that has been shown to be effective is tramadol. Any medication given to patients with fibromyalgia should be started slowly and increased carefully over time.

Psychiatrists and other mental health professionals are important in the evaluation of coexisting primary mood disturbances, such as depression or anxiety disorders, and they are knowledgeable about the use of many of the currently recommended therapies for the treatment of fibromyalgia.[5] In the future, they may also play a larger role in assuming the primary pharmacologic management of many fibromyalgia patients. Currently, most other medical specialists function as consultants rather than assume the primary management of patients with fibromyalgia. Rheumatologists should provide education and advice to the primary care provider and help confirm the diagnosis of fibromyalgia. Rheumatologists should assume the lead in the diagnosis and management of patients with fibromyalgia who also have concurrent rheumatic diseases, such as osteoarthritis and rheumatoid arthritis. They also may take over the primary care of fibromyalgia patients who are not responding to initial management.

Physical medicine and rehabilitation specialists should help coordinate nonpharmacological management, including physical therapy, and evaluate patients for interventions such as selected tender-point or trigger-point injections. The efficacy of these injections is unclear. Some physiatrists do take primary responsibility for patients with fibromyalgia. Neurologists, on the other hand, have, in general, not participated in the active management of fibromyalgia, although hopefully that may change in the future.

Most pain management specialists in the United States have been oriented to procedures that tend not to be effective in the management of fibromyalgia. However, programs that have more of a biopsychological model can be very helpful in patients not responding to initial management.

In conclusion, advancing the optimal management of fibromyalgia will require an earlier diagnosis and greater awareness of this condition by primary care clinicians. Individualized therapy with both physician and non-physician input and multidisciplinary team care will be important in improving the outcome of patients with this common and controversial illness.

One of my main objectives when working with people undergoing chronic pain management is to teach them as much as possible about not only their pain problem, but also about how making positive choices contributes to a solution. A friend and colleague of mine was subjected to a DEA and Medical Board examination and was complimented on how well he had set up the patient education portion of his practice—especially regarding medication management.

Patient education, however, is only one part of the solution. Health care providers making and prescribing chronic pain management medications also need education especially when prescribing medications that were originally developed, tested and approved for acute pain conditions.

While exploring potential continuing education courses on Medscape.com I came across an article titled FDA's Long-Awaited Opioid Plan Includes Mandatory Education by Allison Gandey (a journalist for Medscape). I believe this post to be a fairly balanced coverage of a very charged issue. Unfortunately, as you will see from other experts' discussions in this article, I do not believe the proposed FDA plan goes far enough. This is due in a large part because the mandatory part is "optional" for prescribers and would require legislative changes to be put into effect which is unlikely to happen in a timely manner. At this point it only covers extended-release medications and not the immediate-release types.

Excerpts are posted below. To read the entire article you will need to sign up for a free membership at Medscape, then search for this article by title.

The US Food and Drug Administration (FDA) has unveiled its long-awaited opioid plan that will change the regulations for long-acting and extended-release opioids. More than a million prescribers are currently registered with the Drug Enforcement Administration (DEA) to distribute opioids. Approximately 700,000 of these prescribe long-acting and extended-release products.

The central component of the new opioid Risk Evaluation and Mitigation Strategy (REMS) is an education program for prescribers. The agency will require drug makers to provide and pay for the plan, although the training is still not mandatory for prescribers… Long-acting and extended-release prescription opioids can provide effective pain management for appropriately selected patients when used as directed, the FDA pointed out in an online news release. "However, there are serious risks associated with patients being prescribed these drugs who shouldn't take them or accidental or intentional improper use."

The plan is part of the White House's first national action plan to fight prescription drug abuse announced last week. The Office of National Drug Control Policy, the DEA, and the FDA are banding together to address the problem they say has become "an epidemic." Drug overdose death rates in the United States are at an all-time high. According to some reports, there are more deaths from opioid overdoses than from heroin and cocaine overdoses combined. In some states, these rates are higher than deaths from automobile crashes. In addition to the clear human costs, an estimated 60% of hospital costs related to opioid overdoses are paid for with public funds.

The FDA is now asking the US Congress to pass legislation that would link mandatory physician training to obtaining a DEA number that physicians now need to prescribe controlled substances.

An FDA advisory panel on this issue strongly supported such legislation. As it stands now, the education programs will be mandatory for drug makers but voluntary for prescribers. The FDA will not require any formal prescriber enrollment or real-time verification of training.

Physicians Could Opt Out

The FDA dropped a number of early ideas, such as prescriber accreditation and patient registration programs. Bob Rappaport, MD, from the Office of Drug Evaluation, said last summer that those plans were abandoned because of concerns over how onerous it might be to track close to a million prescribers. Some patients, he said, also complained about possible registration requirements.

The agency presented the watered down approach to an unusually large 35-member panel. The FDA had called on members from multiple committees to weigh in, and they voted overwhelmingly against it. In the 25 to 10 vote rejecting the proposal, committee members said they disliked the idea of optional physician training and the exclusion of immediate release formulations in the plan.

Those casting votes were from the Anesthetic and Life Support Drugs and the Drug Safety and Risk Management advisory committees. Most agreed safety measures for opioids are urgently needed but voiced concern that the current approach does not go far enough to protect the public.

We all support mandatory training, but that would require legislative change.

"I voted no," committee chair Jeffrey Kirsch, MD, from the Oregon Health and Science University in Portland, said at the July meeting. "I fully support that REMS [Risk Evaluation and Mitigation Strategy] is a critical requirement of provider learning, but these initiatives will need to establish definite competencies and assessments." Dr. Kirsch also pointed out at the meeting that both immediate-release and extended-release formulations "have a huge impact on public health."…

FDA officials say they will begin with long-acting and extended-release opioids because the amount of opioid contained in these formulations is much greater than the amount contained in immediate-release drugs.

Regulators told reporters attending a news conference they may revisit adding immediate release opioids at a later date.

Janet Woodcock, MD, director of the FDA's Center for Drug Evaluation and Research, said drug manufacturers will be responsible for tracking how many physicians opt in for the education programs. "This will not diminish abuse or misuse and will very likely result in decreased access to appropriate therapy for some legitimate patients". Dr. Woodcock said they have already contacted the companies involved. "We all support mandatory training," she added, "but that would require legislative change."…

Many psychiatrists and addictions specialists are in favor of the FDA plan. The American Psychiatric Association issued a statement saying it supports the move. The American Osteopathic Academy of Addiction Medicine and the American Academy of Addiction Psychiatry have also issued statements of support.

The American Pain Society has not yet weighed in publicly. Its public policy committee is scheduled to meet next month to discuss the issue at the group's annual meeting. Medscape Medical News will be reporting onsite in Austin, Texas.

In June 2009 a Federal Drug Administration (FDA) panel voted narrowly (20 to 17) to recommend a ban on Percocet and Vicodin, two of the most popular prescription painkillers in the world, because of their effects on the liver.

In January 2011, the Food and Drug Administration (FDA) took new steps to reduce the risk of severe liver injury associated with acetaminophen, a widely used pain- and fever-reducing drug. Rather than banning medications like Percocet and Vicodin, the FDA chose a more moderate course by limiting the allowable amount of acetaminophen in such pills.

The FDA announced it is:

• Asking all makers of prescription products that contain acetaminophen to limit the amount of the drug to 325 milligrams per tablet or capsule.

• Requiring a boxed warning on all prescription acetaminophen products that highlights the potential risk for severe liver injury. Boxed Warnings are FDA's strongest warnings for prescription drug products, used for calling attention to serious or life-threatening risks.

In addition, FDA is requiring a warning on labels of all prescription products that contain acetaminophen that highlights the potential for allergic reactions. These allergic reactions include swelling of the face, mouth, and throat; difficulty breathing; itching; and rash.

Used effectively in both prescription and over-the-counter (OTC) products, acetaminophen is among the most commonly used drugs in the United States. Also called APAP, acetaminophen is used in many prescription products in combination with other drugs, usually opioids such as codeine (Tylenol with Codeine), oxycodone (Percocet), and hydrocodone (Vicodin).

Please visit the FDA Website to read the entire report.

I still advocate that anyone in treatment for chronic pain needs to develop a safe and effective medication management plan, if they are on any medications that have serious risk factors along with other non-medication components. An important part of developing an effective chronic pain management plan is to first understand what an effective plan looks like. I recommend a three part approach:

1. A comprehensive medication plan which includes a medication management agreement;

2. Cognitive-behavioral treatment that addresses pain versus suffering by learning how to managing thoughts and feelings, as well as changing self-defeating behaviors and problematic social/family reactions; and

3. Implementing nonpharmacological (non-medication) interventions which support the development of safer ways to manage pain.

You can learn more about developing a safe medication management plan in my article titled 12 Personal Action Steps for Chronic Pain & Medication Management. You can download for free on our Articles Page.

It is estimated—and has been my personal observation—that as many as half the people seeking treatment for pain do not fully understand the pros and cons of the medication they are taking. This often leads to compliance issues and adhering to a medication management plan. Many of them are reluctant to ask their doctor about the side effects of medicines for fear of being reprimanded.

Since I live in California I want to focus on the regulations we have for medications used in pain management. California has one of the oldest set of rules regulating the use of controlled substances to treat pain. It is also one of the states that maintains an updated site and provides materials easy to locate on the Medical Board's Website.

Below is a section on informed consent from the California Medical Board's Website.

Informed Consent
The physician and surgeon should discuss the risks and benefits of the use of controlled substances and other treatment modalities with the patient, caregiver or guardian.

Annotation
A written consent or pain agreement for chronic use is not required but may make it easier for the physician and surgeon to document patient education, the treatment plan, and the informed consent. Patient, guardian, and caregiver attitudes about medicines may influence the patient's use of medications for relief from pain.

The [California] Medical Board expects physicians and surgeons to follow the standard of care in managing patients with pain and to use the following guidelines when doing so.

History/Physical Examination
The physician must accomplish a medical history and physical examination, which includes an assessment of the pain, physical and psychological functioning, a substance abuse history, history of prior pain treatment, an assessment of underlying or coexisting diseases or conditions, and documentation of the presence of a recognized medical indication for the use of a controlled substance. The physician should take care and realize that "the prescribing of controlled substances for pain may require referral to one or more consulting physicians." Likewise, "the complexity of the history and physical examination may vary based on the practice location. In the emergency department, the operating room, at night or on the weekends, the physician and surgeon may not always be able to verify the patient's history and past medical treatment. In continuing care situations for chronic pain management, the physician and surgeon should have a more extensive evaluation of the history, past treatment, diagnostic tests and physical exam."

Treatment Plan, Objectives
The physician should create a treatment plan that states objectives by which the treatment plan can be evaluated, such as pain relief and/or improved physical and psychosocial function, and should indicate whether any further diagnostic evaluations or other treatments are planned. The physician and surgeon should tailor pharmacologic therapy to the individual medical needs of each patient. Multiple treatment modalities and/or a rehabilitation program may be necessary if the pain is complex or is associated with physical and psychosocial impairment. Physicians and surgeons may use control of pain, increase in function, and improved quality of life as criteria to evaluate the treatment plan. When the patient is requesting opioid medications for pain and inconsistencies are identified in the history, presentation, behaviors, or physical findings, physicians and surgeons who make a clinical decision to withhold opioid medications should document the basis for their decision.

Informed Consent
The physician and surgeon should discuss the risks and benefits of the use of controlled substances and other treatment modalities with the patient, caregiver or guardian. The California Medical Board does not require a written consent or pain agreement for chronic use but suggests that such a document may make it easier for the physician and surgeon to document patient education, the treatment plan, and informed consent. Patient, guardian, and caregiver attitudes about medicines may influence the patient's use of medications for relief from pain.

Periodic Review
The physician and surgeon should periodically review the course of the patient's treatment and any new information about the cause of the pain or the patient's state of health. Continuation or modification of controlled substances for pain management therapy depends on the physician's evaluation of progress toward treatment objectives. If the patient's progress is unsatisfactory, the physician and surgeon should assess the appropriateness of continued use of the current treatment plan and consider the use of other therapeutic modalities. It is important to note that the management of patients with controlled substances requires monthly, quarterly, or semiannual visits as required by the standard of care. The patient's satisfactory response to treatment may include the patient's decreased pain, increased level of function, or improved quality of life. Physicians should consider information from family members or other caregivers in determining the patient's response to treatment.

Consultation
The physician and surgeon should consider referring the patient as necessary for additional evaluation and treatment to achieve treatment objectives. Complex pain problems may require consultation with a pain medicine specialist. In addition, physicians should give special attention to those patients with pain who are at risk for misusing their medications, including those whose living arrangements pose a risk for medication misuse or diversion. The management of pain in patients with a history of substance abuse requires extra care, monitoring, documentation, and consultation with addiction medicine specialists, and may entail the use of agreements between the provider and the patient that specify the rules for medication use and consequences for misuse. It is very important for the physician to coordinate care when prescribing controlled substances on a chronic basis. In situations where there is dual diagnosis of opioid dependence and intractable pain, both of which are being treated with controlled substances, protections apply to physicians and surgeons who prescribe controlled substances for intractable pain, provided the physician complies with the requirements of the general standard of care and California Business and Professions Code section 2241.5.

Records
The physician and surgeon should keep accurate and complete records according to items above, including the medical history and physical examination, other evaluations and consultations, treatment plan objectives, informed consent, treatments, medications, rationale for changes in the treatment plan or medications, agreements with the patient, and periodic reviews of the treatment plan. Physicians should document periodic reviews at least annually or more frequently as warranted. Physicians should document pain levels, levels of function, and quality of life. Medical documentation should include both subjective complaints of patient and caregiver and objective findings by the physician.

Much of the chronic pain treatment research over the past several years is clear that early multidisciplinary treatment interventions lead to improved outcomes. Even with this research, many people are still only offered medication interventions. It sometimes takes a year or more before other nonpharmacological modalities are considered. By that time many of people will have developed a chronic pain syndrome and possibly one or more coexisting psychological disorders, including addiction.

Over the past 28 years of working with people undergoing chronic pain management treatment with coexisting disorders I've found the best outcomes were experienced by proactive patients. They are the ones who became active participants in their own healing process rather than passive recipients.

Since chronic pain is a biopsychosocial condition, it makes sense that treatment would include all of these domains. One important part of the biological treatment plan for many people living with chronic pain should be physical therapy. http://www.wcpt.org/node/29599 The World

Confederation for Physical Therapy defines it as:

Services to individuals and populations to develop, maintain and restore maximum movement and functional ability throughout the lifespan. This includes providing services in circumstances where movement and function are threatened by ageing, injury, disease or environmental factors. Functional movement is central to what it means to be healthy.

Physical therapy is concerned with identifying and maximizing quality of life and movement potential within the spheres of promotion, prevention, treatment/intervention, habilitation and rehabilitation. This encompasses physical, psychological, emotional, and social well being. Physical therapy involves the interaction between physical therapist, patients/clients, other health professionals, families, care givers, and communities in a process where movement potential is assessed and goals are agreed upon, using knowledge and skills unique to physical therapists.

Physical therapists are qualified and professionally required to:

• Undertake a comprehensive examination/assessment/evaluation of the patient/client or needs of a client group;

• Formulate a diagnosis, prognosis, and plan;

• Provide consultation within their expertise and determine when patients/clients need to be referred to another healthcare professional;

• Implement a physical therapist intervention/treatment programme;

• Determine the outcomes of any interventions/treatments; and

• Make recommendations for self management.

The physical therapist's extensive knowledge of the body and its movement needs and potential is central to determining strategies for diagnosis and intervention.

Assessment includes:

• the examination of individuals or groups with actual or potential impairments, activity limitations, participation restrictions or abilities/disabilities by history taking, screening and the use of specific tests and measures; and

• the evaluation of the results of the examination of individuals/groups and/or the environment through analysis and synthesis within a process of clinical reasoning to determine the facilitators and barriers to optimal human functioning.

Diagnosis and prognosis arise from the examination and evaluation and represent the outcome of the process of clinical reasoning and the incorporation of additional information from other professionals as needed. This may be expressed in terms of movement dysfunction or may encompass categories of impairments, activity limitations, participatory restrictions, environmental influences or abilities/disabilities.

Prognosis (including plan of care/intervention) begins with determining the need for care/intervention and normally leads to the development of a plan of care/intervention, including measurable outcome goals negotiated in collaboration with the patient/client, family or care giver. Alternatively it may lead to referral to another agency or health professional in cases which are inappropriate for physical therapy.

Intervention/treatment is implemented and modified in order to reach agreed goals and may include manual handling; movement enhancement; physical, electro-therapeutic and mechanical agents; functional training; provision of assistive technologies; patient related instruction and counseling; documentation and co-ordination, and communication. Intervention/treatment may also be aimed at prevention of impairments, activity limitations, participatory restrictions, disability and injury including the promotion and maintenance of health, quality of life, workability and fitness in all ages and populations.

This month I wanted to explore some of the latest news in physical therapy to share with visitors to our website. One article I discovered on EveryDayHealth.com is titled Physical Therapy for Pain Management by Diana Rodriguez and medically reviewed by Pat F. Bass III, MD, MPH. Some excerpts are below and you can read the entire article at the Every Day Health website.

Chronic pain may leave you wanting to curl up in bed with a heating pad and a bottle of medication to help ease your aches. Although doing exercise may sound like sheer torture, it may actually be one of the best pain management options for your chronic pain.

"Physical therapy can be highly effective for all types of chronic musculoskeletal and neuropathic types of pain," says Tom Watson, PT, DPT, clinical director of Peak Performance Physical Therapy in Bend, Ore.

Physical therapy involves a number of different types of pain management methods, says Watson, including:

• Massage
• Manipulation of joints and bones
• Manual therapy using hands or tools on soft tissue
• Cold laser therapy to alleviate inflammation and pain and release endorphins
• Micro-current stimulation, which emits alpha waves into the brain and increases serotonin and dopamine to alleviate pain naturally
• Movement therapy and exercise

Within each of these categories, there's much that a physical therapist has to offer as far as variety of treatments. Exercise may involve walking on a treadmill or swimming in a pool, depending on the person's pain and physical abilities. A physical therapist works with each patient to understand his or her particular pain — what causes it and what can be done to manage it. This is the kind of attention that a regular doctor doesn't often have the time to give, but a physical therapist can ask questions and talk about pain issues as you are going through your exercise routine.

Exercising for just 30 minutes a day on at least three or four days a week will help you with chronic pain management by increasing:

• Strength in the muscles
• Endurance
• Stability in the joints
• Flexibility in the muscles and joints

Keeping a consistent exercise routine will also help control chronic pain. Regular therapeutic exercise will help you maintain the ability to move and function physically, rather than becoming disabled by your chronic pain.