23 · Web viewThis intervention has shown positive outcomes addressing widespread pain symptoms.11 The individual in this case was ideal for this intervention because of chronic maladaptive

Physical Therapy’s Role in Examining and Treating Chronic Pain Post Opioid Addiction: A

Case Report

Kathryn Kroszkewicz

Cleveland State University

2PT’s Role in Examining and Treating Chronic Pain Post Opioid Addicition

Abstract

Background 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: 3,479


Background and Purpose

Chronic 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 Review

This 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 Cholesterol

Health Behaviors Smoker (1 pack a day) – Tobacco abuse IV Drug Addiction of Heroin and Methadone (March 2017 to March 2018) Alcohol Abuse COPD Emphysema

Psychological Factors Anxiety Depression Negative Outlook and Attitude Psychological Medications with Side Effects

Activity 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 Counseling


Clinical Impression 1

The 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/cancer

Examination

This 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

Posture Sitting

Standing

_______________________________________________________________________________________________________________________________________________________

Gait

_______________________________________________________________________________________________________________________________________________________

Balance

Single leg stance

_____________________________________________________________________________________________________________________________________________________

Gross Active Range of Motion Lumbar Flexion Extension Lateral Flexion

Rotation

Hip Internal rotation

External rotation Flexion _______________________________________________________________________________________________________________________________________________________

Manual Muscle Test

Rounded shoulders Increased lumbar lordosis

Bilateral knee valgus Forward upper body Frequent weight shifting

Visual inspection of resting sitting and standing posture when unaware of the assessment

Antalgic gait Bilateral Trendelenburg Single point cane

Visual inspection ambulating around clinic

2 seconds Left4 seconds Right

Subjective report of frequent balance loss

History of falls in the last year

Observed during examination

Thorough history intake and subjective questioning

Verbally guided through the different planes of movement and visually observed gross deviations

Min limitation Mod limitation, painL Mod limitation, pain; R Min limitationL Mod limitation, pain; R Min limitation

L normal; R normalL Mod limitation, pain; R Min limitationL Min limitation; R Min limitation


Hip Flexion

Hip Extension Knee Flexion Knee Extension Ankle Dorsiflexion Ankle Plantarflexion _______________________________________________________________________________________________________________________________________________________

Sensation L2 L3 L4 L5 S1

_______________________________________________________________________________________________________________________________________________________

Special 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 Scale

Abbreviations: L = Left, R = Right, Min = Minimal, Mod = Moderate, Pos = Positive, Neg = Negative

Figure 1. Pain Body Diagram______________________________________________________________________

Standard Manual Muscle Test procedure

Light touch along the respective dermatomes

L 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+/5

L Pos; R PosL Neg; R NegL Neg; R NegL Pos; R Neg

L diminished; R intactL diminished; R intactL intact; R diminishedL intact; R intactL intact; R diminished


Clinical Impression 2

This 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.

Intervention

Although 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

Figure 1. Pain Body Diagram______________________________________________________________________


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.11

Aerobic 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 Initial

Pain Neuroscience Education

Aerobic Exercise

Therapeutic Exercises

Therapeutic Alliance

(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 pain

Graded 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 benefits

Seated 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 holds

Develop 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_________________________________________

_________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________


6 week

10 week

RPE = Rate of Perceived Exertion

Aerobic Exercise



Aerobic Exercise



Dance

Swiss Ball Exercises

Graded walking program starting at 500 feet daily with 5/10 RPENuStep 1 x week started at 8-10 minutes with 65 steps per minute

Seated 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 depression

Graded 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 benefits

Seated 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 seconds

Continued 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 depression

Standing: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 movement

Bouncing - 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 ball


Outcomes

The 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

______________________________________________________________________________________________________________________________________________________________________________________

Activity and Participation

Discussion

The 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

-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 Socialization

-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 Owner


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.


References

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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-Naïve Patients With Musculoskeletal Pain. JAMA Netw Open. 2018;1(8).

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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.A1

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23 · Web viewThis intervention has shown positive outcomes addressing widespread pain symptoms.11 The individual in this case was ideal for this intervention because of chronic maladaptive