Chronic Pain and Trauma

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This article was originally published in the Physiotherapy Association of British Columbia’s Digital Directions Magazine

My clinical practice has evolved over the years from working strictly in orthopedics, to shifting to empowering clients to be less dependent on manual therapy, feel like they are the driver in the car of their recovery, and ensure that my relationship with them is more collaborative.

I was curious to get to the “bottom” of why it was difficult for my clients to change the way they moved, their pain, or to adhere to exercise. I went on a deep dive into the literature on pain science, took courses – all the usual things we physios do. But I think the most critical change was that I started to deeply listen to what clients were telling me. They were telling me stories of trauma from often years, decades ago. Many of them were diagnosed with PTSD, anxiety, and/or depression. Initially, I was unsure of what to do with this information; however, I would document what was said and store it away for later, hoping to find guidance or insights that could help me better understand and support my clients.

Over the years I noticed patterns across clients – particularly in clients that stayed with me for longer periods, even when their injuries didn’t seem severe. Then there were the clients with tears streaming down their faces, laughing hysterically, shaking rapidly, when we would perform an exercise or movement that they hadn’t done in (often) years. Some of these clients would even report suddenly remembering memories, feelings or reporting emotions. I kept asking and re-asking myself:

“Where else can I get information to put this all together? What can I do differently or better next time?”

Below I am presenting a sample of the literature that ties some of these pieces together, that shows us how common trauma is, especially in those with chronic pain, how it affects outcomes and how we can be supportive of this population.

My hope is that I can provide you with a plausible foundation that exercise and movement therapy, things that are already in our wheelhouse, might pose an effective means of treatment for this population. Ideally, we could measure our effectiveness in outcomes such as establishing an effective therapeutic alliance as well as reducing pain and disability.

A Sample of The Evidence

Chronic Pain

According to the ICD-11, chronic pain is characterized as pain that persists or recurs for more than three months. Pain severity can be assessed based on the intensity of the pain, pain-related distress, and functional impairment (Treede et al., 2015). In 2003, Moseley posited a fundamental principle that pain is generated in the brain when it perceives a threat to the body tissue and determines that action is necessary. Multiple centers within the brain including the anterior cingulate cortex, insular cortex, thalamus and sensorimotor cortex are involved in processing together as a pain neuromatrix. Please see Moseley’s fun Ted talk on “Why things hurt” for a funny, but informative introduction if you are not familiar with his work. As of December 2022, nearly 8 million Canadians live with chronic pain (Government of Canada website, retrieved May 5, 2023).

Trauma

Individuals may experience emotional and physical effects following exposure to traumatic events such as violence (e.g., physical or emotional abuse, assault, war), natural disasters, car accidents, and other incidents. These events can act as triggers that initiate a physical, cognitive, and emotional response known as a trauma response, activated by the perception of harm or life-threatening circumstances caused by a single traumatic event or a series of incidents or circumstances (CDC, 2022). A 2014 report revealed that 32% of Canadian adults reported experiencing physical abuse, sexual abuse, and/or exposure to intimate partner violence during their childhood (Afifi et al., 2014). Another Canadian study in 2021 by Joshi et al., reported that among 44,817 participants, 61.6% disclosed exposure to at least one Adverse Childhood Experience (ACE). Physical abuse (25.7%), intimate partner violence (22.4%), and emotional abuse (21.8%) were found to be the most common types of ACEs. For further information about ACEs, please see the resources below. Of those who have experienced trauma, 5-10% of will develop PTSD. (www.ptsd.va.gov). It is clear from the evidence that chronic pain and trauma commonly exist in the lives of Canadians. I was curious:

“How are chronic pain and trauma related?”

The Chronic Pain/ Trauma Relationship

A swath of research which illuminates the relationship of chronic pain with anxiety, depression (Pinheiro et al., 2016) and emotions (Dahlke et al., 2017), so it doesn’t seem so far removed that trauma and chronic pain could also be related. The evidence suggests that persons with a past history of trauma have a much higher risk of chronic pain. A study by McFarlane, Atchison, Rafalowicz & Papay, (1994) demonstrated that up to 80% of patients diagnosed with PTSD also experience comorbid chronic pain. Those who reported distressing adverse experiences in childhood report more chronic comorbidities including more chronic back pain and headache (You et al., 2019). The authors note that persons with multiple adverse events as identified on the Early Traumatic Inventory Self-Report (ETISR) had an increase prevalence of a chronic pain condition, chronic back pain, chronic headache, and or dysmenorrhea (even after controlling for types of trauma, gender, substance abuse, psychiatric conditions, and somatization tendency) (You et al., 2019). Higher scores on the Adverse Childhood Experiences (ACE) are associated with conditions such as arthritis/rheumatism, severe and/or frequent headaches, back or neck pain, and anxiety and mood disorders (Sachs-Ericsson et al., 2017). This knowledge could help predict the probability for development of chronic pain in our patient populations. For example, a longitudinal study of individuals who experience childhood abuse or neglect found that PTSD in young adulthood and childhood trauma together produced a robust prediction of pain in middle adulthood (Raphael & Widsom, 2011).

Musculoskeletal Injuries and Motor Vehicle Accidents

Further evidence suggests that female gender, anxiety and pre-trauma depression affect the length and quality of recovery from injury (Lewis et al., 2014) and even acute MSK injury (Walton et al., 2013, Modarresi et al., 2019). Research also reveals that after a motor vehicle accident there is little to no connection between the crash variables (e.g. speed, direction, and awareness of impact) and the levels of pain and distress experienced (Lewis et al., 2014). Walton et al., (2022) also found that there were existing, non-linear relationships between severity of injury and health outcomes in persons presenting to hospital care following a non-traumatic MSK injury.  Using the Traumatic Injuries Distress Scale (TIDS), which measures uncontrolled pain, negative affect, and intrusion/hyperarousal, the authors found the following: TIDS scores were higher in those with pre-existing psychiatric or pain condition, and were inversely related to level of education. Walton et al., (2022). This information could prompt physiotherapists to explore a more in-depth mental health history in a post-MVA assessment.

“How does this fit with clinical practice?”

Treatment options

Now that we are knowing a little bit more about trauma and its relationship with chronic pain, we should become familiar with some research that explores how we as physiotherapists could treat, within our scope of practice, clients who experience/experienced trauma.

Yoga

A number of studies have shown that yoga is an effective tool in managing the physiological and psychological effects of ACEs. It is proposed to assist in regulating the body’s physical response to stress by restoring the balance between the sympathetic and parasympathetic nervous systems, reducing allostatic load and cortisol levels, and elevating levels of GABA (Streeter et al., 2012). This helps to alleviate symptoms associated with psychiatric conditions that are exacerbated by stress, such as PTSD, depression, and anxiety (Gothe, Keswani, & McAuley, 2016;). By modifying heart rate variability, yoga promotes increased parasympathetic activity over sympathetic activity, thereby enhancing cardiovascular function and supporting the autonomic nervous system (Vinay, Venkatesh, & Ambarish, 2016).

In a case series from Braun et al., (2021) of seven women with sexual PTSD, yoga and mindfulness sessions once a week for 12 weeks resulted in stress reduction, improved relaxation, mindfulness, self-compassion, and improved affect regulation. The sessions included cognitive reappraisal and use of yogic strategies such as breathing or yoga postures to soothe distressing emotions.

A randomized controlled trial involving 64 adult women with chronic and treatment-resistant PTSD showed compelling results (van der Kolk et al., 2014). Following ten sessions of yoga, participants experienced a statistically significant reduction in the severity of PTSD symptoms and an increased probability of elimination of the PTSD diagnosis when compared to a control of a supportive women’s health education group. Moreover, only the yoga group sustained this improvement in symptom relief during post-treatment follow-up. The effect sizes in this study were comparable to well-researched psychotherapeutic and psychopharmacologic approaches (van der Kolk et al., 2014). According to Van der Kolk and colleagues, practicing yoga can alleviate symptoms of PTSD by assisting clients in managing stimuli that trigger painful reminders of their trauma and their automatic system arousal. Similarly, in a 4-year pilot study, Chopin & Sheerin (2020) found that providing yoga to veterans with PTSD and chronic pain significantly improved mood, arousal and reactivity, and reduction in fear of movement.

Multimodal Treatment

It is important, and feasible, for physiotherapists to work in conjunction with psychotherapy modalities to better serve our clients. An increasing number of papers are exploring the use of movement therapy (e.g. yoga) in conjunction to psychotherapy and or mindfulness with persons with Post Traumatic Stress Disorder (PTSD). Weisfeld and Dunleavy shared interesting insight in a 10-year case study of a client with chronic low back pain (LBP) and delayed-onset chronic PTSD related to sexual trauma experienced as younger adult. The client worked with 2 psychotherapists, a physiotherapist and performed a home-based Pilates exercise program to manage her PTSD and LBP (Weisfeld and Dunleavy, 2021). The authors proposed that exercise allowed the client to practice behavioural changes and apply coping strategies introduced by her psychotherapist including breathing techniques. Further, they stated that alternative therapy including physical therapy, Pilates-based exercise therapy and psychotherapy resulted in improvements with “fluctuating elevations in symptom levels when normal stressors arose, overall concluding with evidence of improvements in function and quality of life.”

Below is a quote from the client that might provide context that this type of treatment may be effective:

“Reducing physical pain and reducing hypervigilance, panic attacks, and dissociative responses, but that was not the central goal; the work on reducing pain and PTSD symptoms was in service to goals related to quality of life …. I will forever be grateful that I found physical therapists and psychotherapists who respect my values and preferences, and who respected each other’s expertise enough to collaborate in treatment across their disciplines.”

Graded Exposure

In preliminary research, Wald and Taylor reported in a 2005 case study the benefits of using trauma related exposure therapy (TRE) with interoceptive exposure therapy (IE) (administered by a psychologist). The TRE and IE was described as asking the participant to hyperventilate for 2 min to induce palpations and dizziness to progressively educate the participant not to catastrophize those sensations. The premise was to slowly expose their participants to symptoms of hyperventilation that had a lot of similarities to symptoms they found uncomfortable to them. A subsequent case series that looked at PTSD and chronic pain from (MVAs) found that using TRE and IE (this time progressing from hyperventilation to other activities, in a graded exposure to jogging for 1 min) was potentially an effective intervention (Wald and Taylor, 2010) – for example, three of the five participants were no longer considered to have PTSD by the end of the study. Wald and Taylor worked with study participants to reframe the anxiety they were feeling was related to a faster heart rate is typically associated with feelings of anxiety (Asmundson et al., 2002)., and that people often adapt behavioural avoidance with anxiety sensations (AS) in chronic pain conditions. This work is interesting, as it looks at graded exposure to sensations, and as a practitioner I see this clinically that when we have persons with trauma, and we reintroduce them to exercise/ activity they can often have sensations/symptoms and or feelings of panic when we help them start moving again. Although recognizing that these case histories are a lower level of evidence, I feel that this work is important in highlighting that it might be possible to teach clients that the sensations they experience are normal (similar to educating that delayed onset muscle soreness is normal), and hopefully this might help clients with their rehabilitation.

Trauma-Informed Physiotherapy Practice

We know that therapeutic alliance is so important for optimal care of our clients. In building a therapeutic alliance with our clients that have a past history of trauma, we must look at the evidence that helps inform best practice. In one study, all clients who self-identified as female survivors of childhood abuse shared that their past abuse was relevant to the therapeutic relationship with a physiotherapist (Teram, Schachter & Stalker, 1999). These findings were similar to the case study mentioned above by Weisfeld and Dunleavy (2021) providing a consistent message from clients that this type of integrated care is important to them.

Using grounded theory research methods, Teram, Schachter, and Stalker (1999) aimed to explore the experiences of 27 survivors of sexual abuse and uncovered the following findings:

Appropriate responses to a client disclosing their trauma history to you as a physiotherapist:

  • Normalizing if a client discloses to you – “Many women have told me that something like this happened to them” or “Physical therapists are learning more about this problem all the time”
  • Expression of understanding and support – “I am sorry that happened to you” or “I am glad you felt you could tell me that”
  • Exploration of practical issues – “What sort of support system do you have?” or “Tell me if I am doing something that doesn’t feel right to you”

It is also important to highlight that these authors discuss that there are multiple needs from survivors and that it not expected that a PT will be able to fulfill the expectations of all survivors. They add that the PT should be clear with themselves, and their clients, about what they can and cannot do.  Further, they implore that they talk with clients about what is involved within physical therapy and how our treatment may interact with survivors’ sensitivities.

In conclusion, my interpretation of the literature shared in this article highlights that there is a link between a history of trauma in clients and their chronic pain. We know that the relationships between predisposing factors and chronic pain are often non-linear, and thus clinicians have to appropriately collect, and identify information in the history that might pertain to predicting the outcome of a client. Once a history of trauma is acknowledged appropriately and rapport is established, a physiotherapist could also inquire about current and past access to psychotherapy/counselling and other coping mechanisms/skills that clients have utilized to manage symptoms that might be trauma related. An open and collaborative discussion with a client could then include the option of using movement therapy. Future research might include exploring the history of past trauma and its implications on recovery from acute MSK injury, how persons with a trauma history perceive neural, stressful and non-stressful events, how that affects their outcomes, as well as how changing variables like heart rate variability/heart rate/sympathetic drive affects symptoms of PTSD/ Trauma.

If you have additional interest in better understanding what trauma is and how we can build a therapeutic alliance with your clients, please explore the additional resources below.

Resources
Bibliography
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