We are all used to the idea of physical therapy. Someone with bulges in all the right places comes along and massages, manipulates, and generally pummels us until the WWF referee decides that's the best of three submissions, and the pain stops. Yes, that's right. The research evidence confirms that almost all the forms of physical therapy, both medically approved and "alternative", do produce real improvements in the health and mobility of the patients. In part, this may be the placebo effect, i.e. you believe all this effort is having a good effect so you feel better. No matter what the reason, the fact most people do feel better after physical therapy is a good result. But physical therapy is now being placed into a broader framework which we are calling pain management. There are going to be times when you may benefit from guided exercises to rebuild strength and encourage mobility, or feel joints eased after manipulation. Equally, there may be times when you just need someone to sit down with you and talk.

Cognitive behavioral therapy (CBT) is now widely used in Europe and is occasionally available for private patients in the larger US cities. This starts with the "cognitive" element. The medical research provides good quality evidence that we all respond better to treatment if we understand all the medical stuff involved. So the therapy starts with a question and answer session to bring everyone up to speed on the nature of the pain, what's likely to be causing it, how the treatment to date has attempted to help, and so on. Once you understand the extent of the problem, the discussion moves on to the strategy for improving your quality of life.

This is the "behavior" element. Let's say you have difficulty walking, the therapist will start off with practical suggestions on how you might redesign your home to make everything more easily accessible, how you might organize work, and what physical therapy might strengthen muscles and improve mobility. Everything is aimed at giving you practical hints and tips for immediate use. The idea is that you change your activities around to make the best of your limited ability to move. By optimizing your physical resources, you get a better quality of life. The therapist may come to your home or visit your workplace to talk you through how best to implement the suggestions.

Overall, the intention is that, within a limited number of meetings with the therapist, you learn the basics of how to get the best out of life. The expectation is that, wherever possible, you will turn your life around without the help of Ultram or any of the other painkillers. These drugs are not cheap and, over months or years of use, the bill soon mounts up. CBT may be a more expensive initial payment, but if you can learn how to cope without Ultram as a regular drain on your finances, this is a big saving over your lifetime. This does not deny you the freedom to take the painkiller should pain flare up. But the hope is to keep the need to the absolute minimum.