Chapter 22 Physical Medicine and Rehabilitation Approaches to Pain Management Flashcards
KEY POINTS 1. Pain management is the first step in restoration of function. Functional improvement is not always synonymous with alleviation of pain. 2. Physical modalities (ultrasound, hot packs, etc.) may be of benefit in acute pain situations. Chronic use of these interventions should be discouraged. 3. Exercise treatment is a helpful adjunct in treating patients with all types of pain disorders. Exercise programs should include flexibility, muscle strengthening, and aerobic exercise. 4.
Therapeutic programs often include
medication and exercise for flexibility, strength, and fitness,
and may use passive modalities, injections, interventional treatments and cognitive and behavioral interventions
Treatment programs for acute pain focus on
addressing the pain generator, using temporary relative rest if indicated, and education for stretching, strengthening, fitness, and proper biomechanics.
Programs for chronic pain
include
exercise regimens, but often require behavioral and
psychological interventions, and direct treatment of the
pain generator itself is rarely effective
Physical therapy
includes therapeutic exercise, functional training in home and work activities, manual therapy, prescription and application of
devices, and passive modalities
goals of pain treatment programs
self-efficacy, return of functional capacity, and
acceptable analgesia
Modalities
methods used by therapists to exchange energy with tissues with the goal of creating a therapeutic response. Modalities are an adjunctive treatment included as part of a rehabilitation program, rarely used in isolation.
Passive modalities may include
the application of heat, cold, sound waves, electricity, and electromagnetic waves to effect changes in tissue structures such as muscle,
fascia, ligament, tendon, capsule, and nerve
Modalities are most useful when treating
acute pain where the specific underlying musculoskeletal abnormalities can be matched with an appropriate intervention. The long-term use of modalities is discouraged, since they may reinforce passive coping behavior
Therapeutic heat transfer occurs by one or a combination of mechanism
radiation, conduction, convection, conversion,
and evaporation.
Radiation
the transfer of heat through
thermal radiation at the surface
Conduction
is heat exchange through direct contact
Convection
is characterized by transfer of thermal energy through movement in a fluid medium, although the therapeutic energy exchange still occurs through conduction
Conversion
occurs when a different type of energy is converted to heat energy
Evaporation
results in loss of heat when a liquid on a surface undergoes a phase transition into a gas
mechanism can be used to transfer heat to structures deeper than several centimeters beneath
the surface.
only conversion. Remaining mechanisms are able to provide only superficial exchange of thermal energy.
Mechanism ways that cold can be applied
Conduction,
convection, and evaporation
Applying heat causes improved
elasticity of soft tissue as well as increased blood flow, metabolic activity, enzymatic activity, oxygen demand, and capillary permeability
Nerve conduction velocity increases with
application of heat.
The heated tissues become
more supple, and there
are increases in healing cells and nutrients and decreases
in metabolic waste
complications of heat
heat can also increase
edema and bleeding
The target temperature for these modalities is generally accepted to be
40° to 45° C, and the thermal pain threshold is normally
about 45° C
Indications for Therapeutic Heat
Muscle spasm, Pain, Contracture, Hematoma resolution, Hyperemia
Increase collagen extensibility
Accelerate metabolic processes
Contraindications for Therapeutic
Heat
Acute inflammation Hemorrhage or bleeding disorders Decreased sensation Poor thermal regulation Malignancy Edema Peripheral vascular disease Ischemia Atrophic skin or scarred skin Inability to respond to pain
Superficial heat
causes the greatest increase in temperature at the surface of the skin, with less heat penetrating to the deep tissues: about 1° C at a depth of 2 to 3 cm.
Superficial heat Applications
Hydrocollator packs
It is often applied using hydrocollator packs, a variety of fluid baths, and infrared lamps. Hydrocollator packs are
heated to 74.5° C. Several layers of towels are used to prevent burning of the skin and minimize loss of heat to the air.
Immersion of body parts in water around 40° C is another way to apply.
Superficial heat Applications
Paraffin baths
Paraffin baths are typically used for peripheral limbs, especially the hands and arms. Temperatures around 53° C are used because paraffin transfers less heat than water does. Infrared lamps can provide similar warming to tissues if angle of incidence
and distance are optimized.
Superficial heat leads to
mild analgesia and a sense of relaxation
Ultrasound diathermy
can easily heat the bone-muscle interface up to 45° C, even in deep structures such as the hip. Ultrasound generators convert electrical energy
into vibratory energy through the piezoelectric properties of a crystal transducer
When ultrasound vibrations are directed into tissue
they generate heat based on the water and protein content of the tissue, and in areas of transition
between tissue densities, such as at the interface between bone and muscle
Tissues that heat and well poorly during a ultrasound
Tissues that heat poorly due to high water
concentration are fat and skin, and tissues that heat well due to high protein concentration are ligament, tendon,
muscle, bone, and nerve, with bone and nerve heating the most.
Ultrasound may cause
gaseous cavitation and acoustic streaming effects that do not transmit
thermal energy, but may increase tissue pressures and cellular metabolism, and disrupt cell membranes
Phonophoresis
A process in which ultrasound may be used to help deliver analgesics and anti-inflammatories across the skin
Common Uses for Therapeutic Ultrasound
Contractures
Tendonitis
Degenerative arthritis
Subacute trauma
Precautions for Ultrasound
Malignancy Open epiphysis Pacemaker Laminectomy site Radiculopathy Near brain, eyes, or reproductive organs Pregnant or menstruating uterus Heat precautions in general Caution around arthroplasties, methyacrylate, or high-density polyethylene
Applying cold through conduction, convection, or evaporation results in
loss of heat from tissues; this results in vasoconstriction followed by vasodilation, decreased local metabolic activity, decreased enzymatic activity, and decreased
oxygen demand. Tissues and muscles become stiffer, nerve conduction slows, and muscle spindle and Golgi tendon organ activity decreases. Muscle isometric strength increases and rate of muscle fatigue decreases. Cold also results in
analgesia and relaxation
Indications for Cryotherapy
Acute trauma, Edema
Hemorrhage, Analgesia
Pain, Muscle spasm
Spasticity, Reduction of metabolic activity
Precautions and Contraindications for Cryotherapy
Ischemia, Raynaud’s disease or phenomenon
Cold intolerance
Insensitivity
Inability to report pain
Cold
often used during the first 48 hr after an acute
musculoskeletal injury to decrease inflammation, edema, and pain. Cold application should not exceed 30 min and
should not be placed directly over superficial nerves to prevent neurapraxia. the surface of the skin is affected first and most, but after 20 min, tissues 2 cm deep are cooled by about 5° C.
How is Cold applied?
Cold is normally applied in ice packs at –12° C with towels layered over to protect the skin
Cold water immersion
Vapocoolant spray
Cold water (5 to 13° C) immersion can be used but is generally poorly tolerated, although muscle temperatures can decrease by about 6 degrees after 30 min of immersion. Vapocoolant sprayis used for cutaneous anesthesia
Cold and heat can be used together in
contrast baths with alternating warm and cold immersion to cause cyclic vasodilation and vasoconstriction, with beneficial effects
hypothesized for pain from rheumatologic and neuropathic conditions
Iontophoresis
process by which various drugs (i.e., corticosteroids, lidocaine) are introduced into a joint or around periligamentous or tendinous structures via electrical current
How does Iontophoresis work?
uses electromigration and
electro-osmosis to increase permeation of charged and neutral compounds. The medicine is applied to the electrode
with the same charge, and then the electrical field is
set up on the skin surface to push the medicine away from the electrode and toward the target tissue.
Advantages of Iontophoresis
Iontophoresis is non-invasive, painless, and
avoids potential side effects and adverse reactions of oral
medications or injection therapies (i.e., increasing risk for bleeding, intravenous catheter infiltration, and pump malfunction).
Iontophoresis indications
overuse conditions such as epicondylitis and plantar fasciitis
transcutaneous electric nerve stimulation (TENS)
mechanisms of pain relief include modulation of the gating mechanisms at the dorsal horn system to decrease pain transmission to the brain and stimulation of
endogenous neurotransmitters and opioids. Cutaneous
nerve fibers are stimulated using surface electrodes emitting a mild electrical current
Transcutaneous Electric Nerve Stimulation (TENS)
High-frequency low-intensity stimulation and Low frequency high-intensity stimulation
High-frequency low-intensity stimulation patterns are better tolerated and result in immediate analgesia, while low-frequency, high-intensity patterns cause more discomfort
and result in longer-lasting analgesia.
Interferential current therapy (ICT)
uses electrical current like TENS, but combines two different high-frequency pulses so that their interference pattern creates a low-frequency stimulation. The high-frequency stimulation penetrates skin better
than low-frequency stimulation, but the treatment results in
the longer-lasting effects of low-frequency stimulation
Comprehensive Rehabilitation Program
Phases: Theraphy Focus
Acute: Education, relative rest, pain control
Recovery: Full or optimal range of motion, strength, balance, proprioception
Maintenance: Return to work and sport specific activity, aerobic conditioning
Relative rest is important because
excessive immobilization results in decreased muscle strength,
endurance, and flexibility
Therapeutic exercise should begin during
the acute phase
Manual techniques should focus on
improving soft tissue extensibility that helps promote proper alignment of collagen fibers during healing and remodeling. These techniques may include massage, fascial stretching, traction, and joint mobilization
Myofascial release improves
elasticity and motion by applying pressure in shear forces directed by fascial planes, and
assists with pain control
three main types of therapeutic exercise:
exercises that improve flexibility, muscle strength, and aerobic capacity
When implementing an exercise program, the specific adaptation to imposed demand (SAID) principle should be applied
The principle states that the body responds to
given demands with specific and predictable adaptations. Stronger muscles develop with strength training. Oxidative capacities of skeletal muscles increase with aerobic training.
Pliability of connective tissue increases with flexibility exercises
In aerobic fitness Oxygen consumption (VO2) increases in proportion to the intensity of
the exercise. VO2 max, the highest level of oxygen consumption
achieved during exercise, is the best indicator of
aerobic fitness
frequency, intensity, and duration of aerobic training
This is typically at 40% to 85% of VO2 max for
aerobic training. The duration for aerobic training is usually
greater than 15 min of continuous exercise. Frequency for aerobic training is usually 3 to 6 times per week
Treatment approaches for spine-related conditions
flexion-based therapy, stabilization exercises, mechanical diagnosis and treatment (MDT), neurodynamic therapy,
and various manual therapy and soft tissue approaches, as well as activity and therapeutic exercise
Stabilization exercise training
emphasizes not only strengthening muscles but motor relearning of inhibited muscles.
Patients are advanced from training in isometric and eccentric strengthening of core muscle groups to include
Swiss ball and other dynamic multiplanar exercises, and finally gradual return to work- and sport-specific activities.
Stabilization exercises indications
reduce the recurrence
of low back pain from spondylolysis and spondylolisthesis. Stabilization exercises prevent recurrence and
improve pain and function of nonspecific chronic low
back pain, but do not reduce pain or disability in acute low back pain
