How Physiotherapists Approach Pain Assessments and Treatment

In part two of our Physiotherapy for Pain Management blog series, we take a deeper dive how physiotherapists approach pain assessment and treatment and whey they may often take an interdisciplinary approach to support a client in managing their pain. We again sat down with Vivir Healthcare’s Clinical Coordinator for Physiotherapy, Jyoti Chatla to explore the important role physiotherapy plays in pain management where she also shares one of her client success stories! If you have not ready part one of Physiotherapy for Pain Management blog series, you can read it here.

What role does client education play in physiotherapy for pain relief and prevention?

Jyoti: Client education is one of the major components and an integral part of chronic pain management. Pain is a complex, unpleasant feeling and is highly subjective in nature and has strong emotional response associated with it. Due to our experiences with pain with day-to-day living, we form ideas and concepts in our mind which can be dependent on our beliefs, upbringing, or our surroundings and our past experiences.

Clients suffering with chronic pain have several questions related to their condition and need reassurance and education to address their concerns. It is also not uncommon to see clients with chronic pain having ideas or misconceptions such as exercise is harmful, or physical activity is going to aggravate pain, pain is not treatable with exercises, and their condition is not treatable and will need surgery. At times, clients with chronic pain learn to associate pain with movement as being harmful to their body and develop avoidance behaviours in anticipation of pain or risk of reinjury. This in turn leads to a vicious cycle where a client due to their fear of pain with movement avoid movements and activities leading to inactivity and ultimately risk of greater level of disability. This has an impact on their physical state, and it also affects their mental health, sleep, and lead to chronic fatigue.

Client education starts from explaining to the client about the complex nature of chronic pain which extends beyond the timeline of normal tissue healing and is not generally associated with a physical injury or illness. Education and information about why pain with movement is not always damaging or harming their body and does not mean further risk of reinjury or increase in pain is a crucial step for clients with chronic pain. With education, we aim to impart the knowledge to the client that it is ok to move and gradually increase their tolerance of pain to movement by gradually exposing their body to more movement with time to avoid the downward spiral of inactivity. Gradually with exercise and activities, their threshold for pain improves and they will be able to move more with less pain. Certainly, client education is important to develop the client’s positive attitude towards exercise and physical activity.

In addition, education about the importance of activity pacing, self-management strategies such as use of heat and cold packs, relaxation, use of proper body mechanics can improve confidence of the client to help them manage their pain.

Can you share a specific success story where physiotherapy has made a significant difference in pain management for one of your clients?

Jyoti: One of my clients, a 50-year-old lady, used to work as an admin staff and generally led a sedentary lifestyle. She had been experiencing chronic lower back pain for several years. The pain was affecting her ability to perform daily living activities, including work and leisure activities. She had tried various treatments, including medications and chiropractic adjustments, but she never experienced any long-term relief.

She eventually decided to see a Physiotherapist after her friend recommended her to try this treatment because of her own positive experience.On subjective examination, her pain was localised in the ow back area. There was no radiation of pain to her extremities. She didn’t have pain with rest but sitting for more than 15 minutes or standing and walking more than 10 mins were painful for her. On examination, we identified that the client had muscular imbalances, poor posture, and lack of core strength. She had asymmetric tightness in the muscles in both her extremities and had weakness in her posterior chain muscles.

Her treatment was a combination of manual therapy techniques such as soft tissue massage, joint mobilisations to alleviate muscle tension and to improve joint mobility. Additionally, we prescribed her specific exercises to strengthen her core muscles, posterior chain muscles and exercises to improve flexibility in her tight muscles. We started the strengthening programme at a very low intensity as much as she could tolerate and progressed to body weight exercises in a functional pattern.

As her pain levels improved, we commenced the client on a walking programme. We requested her to maintain a diary and record her daily walks, distance/ time she could manage to walk, symptoms that she experienced and how long the symptoms lasted. We educated her with self-management strategies such as bracing her core muscles, taking rest pauses to recover from pain. She was given a home exercise programme that she could complete at home focusing on strengthening and flexibility exercises. Her walking duration improved gradually as her confidence and motivation levels improved and she was able to walk 45 minutes to 1 hour without any complaints of pain.

We also checked her desk and seating set up at work and gave her some recommendations to make the setup ergonomically sound. She was educated about the importance of avoiding prolonged static postures since our muscles and joints are designed to move and not to stay in one position for long duration. We gave her a handout with pictures of exercises that she could do when she was in her office, which were easy and could be performed in an office setup without specific equipment required.

The client continued to maintain her regular walking programme and all the exercises that were given to her. She was not experiencing pain anymore and was happy with the overall outcome she had. She was also looking forward to engaging in activities that she has previously avoided due to fear of discomfort.

How important is interdisciplinary collaboration (e.g., with Occupational Therapists, Dietitians) in managing pain through physiotherapy?

Jyoti: For the best outcome for clients, it is important for a Physiotherapist working with clients with chronic pain to collaborate with other allied health professionals such as Occupational Therapists and Dietitians for overall holistic approach to treatment.

Chronic pain has a strong impact on clients’ lives and their well-being. Due to complexities associated with pain, clients can experience difficulties with their daily living activities, their participation in the community and even their occupations and leisure activities. Occupational Therapists can complete a thorough assessment of a client’s activities, their occupational demands, and the impact of their surroundings and environment on their experience of pain. Due to their expertise and knowledge about adaptive equipment and assistive technologies, Occupational Therapists can work closely with the clients suffering with chronic pain and identify any modifications or adaptive equipment that can make day to day tasks easier for the client. They can also recommend assistive devices / technologies and suggest and make changes to their environment to enable the client to engage in their activities of daily living (ADLS) which promotes independence and therefore feelings of satisfaction amongst clients.

There is a growing body of scientific evidence which has shown that poor nutrition, unhealthy dietary behaviours, and sub optimal nutrition play a strong role in occurrence, development, and prognosis of chronic pain. Clients with chronic pain have several challenges due to their mobility and strength, mental health, irregular sleep habits due to which access to healthy nutritious meals can be a challenge. A well-balanced diet is important for a client with chronic pain to gain benefits from physical activity and exercises. In addition, clients with chronic pain are at risk of various lifestyles diseases and comorbidities associated with reduced mobility, due to which diet is important. Dietitians can work closely with the client, understand their challenges, their requirements and recommend strategies and dietary recommendation personalised to their needs.

How does Vivir Healthcare approach pain assessment and treatment planning during initial client consultations?

Jyoti: Vivir Healthcare Physios complete a comprehensive assessment on their initial appointments. The initial client consultation starts with subjective examination where the clinician asks the client questions about the difficulties they are experiencing in their day-to-day activities, their occupation and leisure. Physiotherapists will collect in depth information from their client about their pain such as the location of pain, severity, type of pain, the aggravating and relieving factors, and changes in levels of pain with time of the day and if the pain is associated with any other kinds of symptoms. Baseline level of pain is documented using pain scales which is used to monitor during follow-up sessions to understand how the treatment planned for the client is helping them. Subjective assessment also includes understanding how pain is affecting the clients’ ADLS and their participation in the community in their occupation, hobbies, and leisure. This information helps the us physiotherapists to get a better understanding of their client’s problem.

The next step in the initial consultation includes completing a thorough physical examination, where we will assess client’s range of motion, strength, balance, their gait. Physiotherapist will also complete some special tests to identify musculoskeletal causes of pain. Standardised outcome measures are recorded at baseline which are re-assessed periodically by the physiotherapist to ensure that the treatment plan designed by the physiotherapist is effective at bringing about some change in client’s symptoms and their function.

Finally, Physiotherapists sets goals in collaboration with the client. Based on the above information and examination, Physiotherapists then develops a personalised treatment plan for the client which includes patient education, manual therapy, exercises. Treatment plans are individualised as per the clients’ goals, their baseline levels of function and exercise capacity and are reviewed and monitored periodically, are adjusted as required to ensure client is progressing safely and has the best possible outcome. Physiotherapist will also give you self-management strategies and a tailor-made home exercise programme with pictures and instructions to help client in between the sessions with physiotherapists. The physiotherapist will guide you through a graded approach of return to activities.

What advice do you have for individuals seeking physiotherapy to manage their pain but are unsure about where to start?

Jyoti: If you are suffering with chronic pain, you should consider seeing a Physiotherapist. In Australia, Physiotherapists are first contact practitioners and therefore you do not usually need a referral from a GP before you see a Physiotherapist.

However, if you would like to claim Medicare rebate, you will need to consult a GP to get a referral via Chronic disease management plan (CDM) or Enhanced Primary care programs (EPCs). CDMs or EPCs is a Medicare rebate system to help refund part of the cost of attending a private allied health service. Each eligible individual can claim 5 sessions per calendar year.

If you have private health insurance, check your policy if it covers Physiotherapy treatments.

If you are over 65 years of age you may be eligible for government funded aged care services, you need an assessment to find out if you are eligible for these fundings. Using this funding you can have access to Physiotherapy services.

If you are already on some form of aged care funding, speak to your case manager who can arrange Physiotherapy services for you.

The next step is to find a Physiotherapy service provider that you would like to use. Vivir Healthcare offers mobile Physiotherapy services and come to your home for all sessions . The first session is an initial consultation during which the physiotherapist will talk to you and take full history of your condition to understand your condition, complete a physical examination and set goals in collaboration with you. Based on this information, they will design treatment plan that will be individualised to you as per your circumstances and goals. The subsequent sessions will be follow-up sessions with your Physiotherapist focussing on the treatment, who will closely work with you and monitor your symptoms and adjust your treatment if required to ensure you get the best possible outcome.

If you would like to book in one of our physiotherapists to help you manage your pain, fill out our referral form here.

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How Vivir Healthcare’s Dietitians can support your facility achieve aged care quality indicator milestones.

By Vivir Healthcare • October 13, 2024

In the aged care sector, allied healthcare professionals play a crucial role in helping facilities and providers meet their 11 quality indicator goals. Among these experts are Dietitians, whose specialised knowledge in food and nutrition can have a positive impact to the health and well-being of care recipients. At Vivir Healthcare, we recognise the importance of nutritional care where our Dietitians are dedicated to supporting aged care facilities and providers around Australia in delivering exceptional care to older adults, helping to improve health outcomes and overall quality of life. In this blog, we will explore the 11 aged care quality indicators and discuss how our Vivir Healthcare Dietitians can support all care recipients while enhancing your facility’s and service's overall performance. Aged care Quality Indicator 1: Pressure Injuries Dietitians are well placed in the prevention and nutritional management of pressure injuries by supporting and maintaining skin integrity. Pressure injuries are common in residential aged care, particularly for residents who are bed or chair bound and non-ambulant. Entirely preventable and combined with regular repositioning, pressure injuries can be prevented with optimum nutrition. Dietitians will focus on ensuring residents receive adequate protein, energy, micro nutrients such as vitamin C, E and minerals zinc and iron. These nutrients are equally important in the management of established pressure injuries. Dietitians can assist residents to increase their protein and energy intake through small dietary changes to support wound healing. Dietitians are also well placed to prescribe wound-specific supplementation. Some residents are more susceptible to pressure injuries and impaired wound healing if they have co-morbidities such as diabetes and/or chronic kidney disease. It’s important that a Dietitian is involved especially when co-morbidities are present as impaired renal function can worsen with high protein intake. A comprehensive nutrition assessment will ensure that appropriate recommendations are made for the individuals unique situation. Aged care Quality Indicator 2: Physical Restraint For residents that live with dementia and experience behavioural challenges because of the disease, at times physical restraint is used to protect themselves and others from potential harm. Residents who have poor nutrition and poor oral intake, may experience an increased rate of progression of cognitive impairment. Dietitians can assist staff and family to ensure residents nutrition requirements are met and work around challenging behaviours with food and mealtimes. Having a Dietitian involved in the care of residents with dementia may help to slow the progression of the illness and may reduce the likelihood of the need for physical restraint. Aged care Quality Indicator 3: Unplanned Weight Loss The main referral received in aged care for dietitians is for unintentional weight loss and malnutrition. Dietitians are at the forefront in prevention and management of weight loss. It is estimated that approximately 60% of residents in residential aged care are either at risk of malnutrition or are malnourished. Unplanned weight loss is a key indicator and risk factor for malnutrition. Unplanned weight loss can occur for multiple reasons in people residing in aged care homes and in the community including; complex medical conditions, hospitalisations and poor appetite to name a few. Dietitians assist to prevent and manage unplanned weight loss and malnutrition by prescribing high energy high protein diets, food-first approaches e.g. food fortification and if necessary, oral nutrition supplements. Dietitians also assist to educate and support care and kitchen staff to optimise residents' diets in the kitchen and/or at the table. Aged care Quality Indicator 4: Falls and Major Injury Most falls and major injuries, while common, are entirely preventable in aged care and in the community. Working alongside allied health professional, for example Physiotherapists , Osteopaths and Occupational Therapists , Dietitians make nutritional recommendations to compliment physical activity to promote optimal muscle mass to support strength and conditioning of skeletal muscle. Adequate nutrition, focusing on adequate protein and energy intake, through dietetic intervention combined with physical exercise can reduce the likelihood of falls and therefore subsequent major injuries such as fractures Aged care Quality Indicator 5: Medication Management Many residents in residential aged care often require nutritional supplementation as the ageing process requires increased nutrition requirements for particular nutrients. Dietitians can support and optimise nutrition intake through food first approaches which may help to reduce the reliance of expensive supplements or medications, decreasing the risk of polypharmacy. Aged care Quality Indicator 6: Activities of Daily Living Dietitians are well placed to support residents and clients with their day-to-day activities. Supporting optimal health to maintain independence for as long as possible. With respect to food and eating, Dietitians can make personalised recommendations to clients and residents around nutritious choices when food shopping, cooking methods and mealtime support. Aged care Quality Indicator 7: Incontinence care A common issue in residential aged care and in home care clients, incontinence can be debilitating and socially isolating. In some cases, Dietitians may be able to relieve the symptoms of incontinence especially if there are dietary triggers, lack of fibre or intolerances. For those that experience incontinence, there are increased fluid losses that require replacement. Dietitians can provide guidance on appropriate fluid intake to ensure adequate hydration. Aged care Quality Indicator 8: Hospitalisation As outlined above with respect to falls and major injury prevention and therefore subsequent hospitalisation, Dietitians also play an integral role in supporting residents and clients upon return home from hospital. In most cases, weight loss is an undesirable consequence of a hospital admission. Residents and/or clients that are hospitalised and are undernourished are at an increased risk of infection, wounds, increased length of stay and increased risk of death. Dietitians can help to correct and stabilise unplanned weight loss and hospital acquired malnutrition and wounds with targeted nutrition support through individualised nutrition assessments. Discharge plans often recommend dietetic input upon return home for those residents and/or clients identified with weight loss and or malnutrition during their hospitalisation. Aged care Quality Indicator 9: Workforce Dietitians make up the important network of allied health professionals that are underutilised in aged care. As outlined above, Dietitians can provide support and value addressing each quality indicator to support positive health outcomes for residents and clients. Dietitians support multiple staff across the aged care setting to enable them to build the capacity of their clients and residents. Vivir Healthcare boasts an experienced, passionate team of Dietitians across Australia, ready and eager to play a role in the care of elderly Australians. Aged care Quality Indicator 10: Consumer Experience Food is an important source of enjoyment for residents and consumers in their day to day lives. Dietitians are uniquely placed to bridge communication between staff, residents and clients to improve the overall dining and mealtime experience. Vivir Healthcare Dietitians regularly complete mealtime assessments and menu reviews in aged care to ensure compliance, enjoyment and nutritional adequacy. Food and eating is an integral part of life and it is up to everyone to enable the consumer experience and choice to be at the centre of their care. Aged care Quality Indicator 11: Quality of Life. As above, it has been addressed how Dietitians can enhance the consumer experience, particularly when it comes to food and mealtimes. Inevitably, there are times when nutrition focuses shift away from corrective and intensive interventions as illustrated under the above quality indicators to individualised, scalable recommendations to preserve and optimise quality of life. Dietitians are often called upon for weight loss the context of progression toward end-of-life care. Some residents and clients may require a palliative approach if they are living with a life limiting illness. Dietitians can ensure that foods and fluids provided align with the residents or client preferences going through this life stage. As with wound care and wound prevention, adequate nutrition is integral to supporting skin integrity to prevent the development of new pressure injuries or sores. Dietitians will make recommendations accordingly and apply dietary strategies to prevent further skin deterioration and improve overall quality of life.

Persist with Resistance - The importance of Resistance Training

By Matthew Williams - Physiotherapist • October 8, 2024

“Have you been doing your exercises?” I wonder if you’ve been asked that question before. Perhaps it was posed to you by a health professional, it may have been posed to you by an inquisitive family member or it may be a question that you’ve posed to yourself? In my role as a physio , I spend a lot of my week doing exercise with clients. Some sessions are focused on strength, some sessions are more targeted towards aerobic fitness, and other times we work on balance, range of motion or any number of other important metrics of physical health. I have clients whose sessions are completed sitting down in a chair and clients who walk for kilometres. I have clients who do hours of exercise every day, and clients who find it hard to get motivated. But in those wonderfully diverse experiences, one consistent theme is the focus and promotion of resistance training. The role of resistance training in maintaining good physical and psychological health has long been testified to. And so, my goal in this article is not to tread over old ground or to walk a well-worn path - though we all need to walk it from time to time. I want this article to present the same message but from a different angle. I want to get practical. I want to give you three thoughts that I try to prioritise when implementing resistance training with clients: The human body has potential. Focus on strength and power. The positive feedback loop. Let’s dive in! The Human Body Has Potential. The human body has so much potential. Whether you’re 50 or 90. Whether you meet the step goals on your apple watch everyday or have never done a day of exercise in your life. You have potential. Research shows demonstrable improvements in quality of life, depression and muscle strength through the performance of resistance exercises. It shows improvement in functional activities like climbing stairs, getting out of a chair, getting dressed and catching the bus. It shows improvements in physical and psychological well-being. It shows improvements in pain. Loss of muscle mass is a gradual process that, on average, begins after age 30 and accelerates after age 60 (Chang et al., 2019). We call this sarcopenia. This diagram shows the negative pathways that can result from sarcopenia and a loss of muscle mass (Hunter et al., 2004).

Falls Prevention Support and Management: When to Seek Physiotherapy and Occupational Therapy Help

By Vivir Healthcare • September 22, 2024

In Australia’s ageing population, falls prevention for elderly people cannot be overlooked. According to the most current 2023 Australian Government statistics, falls contribute to 43% of injuries leading to hospitalisation, making falls the top cause of injury related hospitalisations in Australia, with people aged 65 years and over being the most affected. As the impact of a fall can lead to loss of independence, confidence and impact overall well-being, understanding the role that Physiotherapists and Occupational Therapists play in supporting people implement fall prevention strategies to prevent future fall incidents, and engaging in their expertise, can help improve the quality of life for you or your elderly loved one.

Physiotherapy for Pain Management: Part 2 – Our Success stories and approach to pain assessment and treatment