Countless sprays, lotions, ointments, creams, and salves have debuted over the years, some with elaborate claims and equally strong odors. As these products evolve and filter down from consumers to working therapists, there is a distinct appreciation for the benefits, practical uses, and limitations. Beyond the typical sports-related muscle aches and pains, topical analgesics are being used for fibromyalgia, migraine headaches, and even so-called extreme cluster headaches—the level above migraine.
According to Joe D. Kingsley, president of Sore No More, a division of the Glo Germ Company, Moab, Utah, topicals can even help some patients to migrate away from prescription medications. “Today, arthritis in all its various forms represents the bulk of Sore No More applications,” Kingsley adds. “The main benefits are, of course, pain management. Joint mobility is enhanced mainly due to the reduction of inflammation and pain.”
When it comes to topical analgesics, proponents say that too often PTs think it’s appropriate to simply slather on ointment and wait for the results. Longtime users bristle at this notion and emphasize that proper protocols matter. “It is essential that the spray be applied as the patient exhales,” says Richard Finn, CMTPT, PTS, MCSTT, director of the Pittsburgh School of Pain Management. “The exhalation is absolutely essential to make the product work. That is a huge typical mistake.”
Finn acknowledges lingering skepticism in some segments of the therapy community, a situation he confronted at this year’s American Physical Therapy Association show in Las Vegas. Finn prefers Gebauer’s Instant Ice and Spray and Stretch products, and he largely treats myofascial trigger points. After 3 straight days of treating occasionally skeptical PTs at the APTA conference, he changed a lot of minds. “I used six bottles [of topical analgesic] during that time, all on PTs who had pain, and they all received help,” Finn says. “We did not have a failure.”
Kingsley agrees that fighting negative perceptions is half the battle. “I think the biggest misconception among PTs is the same one I had when we first started working with this concept—the snake oil image,” Kingsley muses. “All-natural, pain-relieving gel just did not seem like it would be as effective as a fancy prescription product. We now have thousands of customers migrating from prescriptions to an all-natural product for treatment of their symptoms.”
Manufacturers and therapists agree that the nonprescription aspect (for some topicals) provides greater flexibility for both treatment and additional opportunities for cash sales. “Historically, the chiropractic market was the only practice to utilize revenue-driving retail techniques,” says Matt Mettler, vice president of Mettler Electronics Corp, Anaheim, Calif. “The trend of offering retail products such as Polar Frost, or hot and cold packs, is finally a normal occurrence in all markets. Why send a patient down the street to a retail chain when they can buy a better product directly from you?”
Generating cash sales within the practice requires a sensitive approach and an awareness that many analgesics can be found at retail settings at often better prices. Lou Paradise, chief of research at Topical BioMedics Inc (makers of Topricin), agrees that PTs can make it work with the right approach. “With an effective product,” Paradise says, “a physical therapy practice can create a valuable profit center.”
Kingsley reports that some pain management clinics have such large after-treatment sales of Sore No More that they have come to rely on it as a sizable income stream within the business. For bulk sales to hospitals, Kingsley sells pails of up to 5 gallons, in addition to the 3/4-ounce tubes.
St Petersburg, Fla-based Orthopedic Pharmaceuticals has also sought to improve delivery systems, making it easier for both therapists and patients with the 6-ounce nonaerosol continuous spray for its ORTHOGEL Advanced Pain Relief line of topical analgesics. “The continuous spray can does not require the patient to pump the bottle, because it contains compressed air to dispense the product onto hard-to-reach areas, such as the middle of the back and lower legs of patients with back problems and arthritis,” says Fred H. Miller, CEO of Orthopedic Pharmaceuticals. “The product contains a higher level of menthol and other ingredients to make it effective for the temporary relief of pain, compliant with FDA topical analgesic guidelines.”
Justin Toups, marketing manager at China-Gel, Arlington Heights, Ill, points out that a tangible item in the patient’s hand goes a long way toward extending care and cementing the relationship. “Every time they use it, they will remember where they purchased it and the services they received,” Toups says. “The name of the therapist will be top-of-mind, ready to refer friends who may be in need of therapy. Topicals are very much a marketing tool, so therapists should choose their topicals well, find a place for them in their practice, and prescribe use during treatment.”
ALL THE ANGLES
In addition to reducing pain, Finn addresses range-of-motion problems that have a myofascial component. Before applying a topical, he puts the muscle on a stretch and demonstrates the restricted motion. During the evaluation, he checks posture, neurological tests, and strength. “When you demonstrate the range-of-motion restriction, and then you use the Spray and Stretch product—and demonstrate the increase in ROM—the patient is blown away,” Finn says. “They see immediate results—better ROM and an immediate decrease in pain.”
If someone comes in with pain in the levator scapulae, Finn says it is a typical mistake among therapists to simply apply the spray, release the muscle, and stop there. Instead, he says therapists should correct the dysfunction of the joint as a whole, or risk not being able to take care of the muscle long term. In short, a protocol is necessary.
“Treat the neurology. Often we’ll spray the suboccipitals just to have a global effect on muscle tightness,” Finn says. “Then I’ll treat the spinal segment controlling the muscle that has the problem. By that time, I often don’t need to spray the muscle that had the original problem. Sometimes there is the full ROM already. But if not, I spray the muscle too.”
As someone who deals primarily with trigger points, Finn uses the spray to block the pain signal to the brain while he stretches out the muscle. “The muscle is anchored down on one level and then the practitioner lengthens the muscle; as the spray is applied, we take up the slack in the muscle and we usually spray two or three times before rewarming the muscle,” Finn explains. “Following that muscle being rewarmed, the patient—after we take him passively through his ROM—does three repetitions of that newfound ROM to retrain that muscle to a normal resting length. Then we follow up with hourly stretching to maintain that for about a 2-week period.”
Since pain is reduced, working the muscle can become easier with analgesics. However, Kingsley warns that therapists should always be aware that pain is perceived differently, even among people with similar injuries. He also cautions to resist the “more-is-better” mentality. “If a little application works, some therapists want to use half the jar,” Kingsley laments. “Another big problem is wrapping the application, and heat builds up to where the heat pain exceeds the muscle pain. We strongly recommend using only the amount that just meets the goal of the client, and not more than three times per day.”
Therapists who have explored the analgesic market know that there is a huge variety of products. What ingredients actually work? It often depends on who you ask. Competition is fierce, and there is not much difference when it comes to cost. “It’s the length of time and duration of the cooling mechanism that make certain products unique,” Mettler says. “Using higher-quality grades of alcohol and menthol is one way to achieve longer and colder results. High-quality analgesics truly work when applied properly. You cannot expect solid relief after one or two treatments. These are products that need to be used on a regular basis, both in and out of the clinic.”
If you’re looking to try new topicals, the good news is that most manufacturers will gladly provide free samples to curious therapists. Virtually every physical therapy facility in the United States uses at least one brand of analgesic, which naturally leads to intense competition and fierce loyalty among early adherents. In fact, many therapists admit to being creatures of habit when it comes to topicals. If they like it, they stick with it. “Just because you have been using a product for several years does not mean that it’s the best product for your patients,” Mettler muses. “Don’t be afraid to try other products. The other misconception is that just because your topical gets cold initially does not mean that it is working. The goal is to provide cooling relief to the muscle and tissue.”
As the inevitable process of evolution rolls on, those who have been in the pain management field for a long time see a growing acceptance among therapists. As someone who has been treating pain since 1984, Richard Finn has seen an increasing number of patients who now stick to the home routines, largely thanks to the efficacy of topicals. “It leads to a major increase in compliance with their home program, because they understand that they are affecting their own problem,” Finn says. “It’s not like you need a goniometer to measure 5 degrees of improvement in range of motion. We almost always get full range of motion in myofascial types of restrictions, or really close to it. It sells the patient, and because of compliance we get better outcomes.”
INDUSTRY INSIDERS IN THEIR OWN WORDS
- Joe D. Kingsley, president, Sore No More Company (a division of Glo Germ), Moab, Utah (www.sorenomore.com): “Topical analgesics are used mainly for pain management, but we are finding that patients and professional practitioners are constantly finding new and effective applications other than pain management. For example, the medical staff at the William Beaumont Army Medical Center in El Paso, Tex, is treating soldiers with diabetes. They found that using Sore No More was the most effective treatment for poor circulation in the feet.”
- Matt Mettler, vice president, Mettler Electronics Corp (makers of Polar Frost), Anaheim, Calif (www.mettlerelectronics.com): “The key ingredients that make these types of products effective are alcohol, menthol, and aloe vera. There are only a few products on the market that have the ability to get cold enough, get deep enough, and last long enough.”
- Fred H. Miller, CEO of Orthopedic Pharmaceuticals (makers of ORTHOGEL Advanced Pain Relief), St Petersburg, Fla: “The bag on valve (BOV) technology uses air to apply the product as a spray. You just hold the nozzle down, similar to a sunscreen can. The BOV makes it a lot more user friendly.”
- Lou Paradise, chief of research, Topical BioMedics Inc (makers of Topricin), Rhinebeck, NY (www.topicalbiomedics.com): “The typical users of most topical analgesics are young athletes who overuse these products and/or mix and match these topicals—or combine them with oral pain medication—significantly increasing the risks of serious side effects. As a natural pain relief and healing technology, there are no such dangers with Topricin.”
- Jim Bilas, director of marketing, Ari-Med Pharmaceuticals (makers of Flexall), Tempe, Ariz (www.ari-med.com): “As a rule, any topical analgesic is not a cure-all, but can be an effective addition to a therapy regimen. For instance, we have completed a study that supports using Regular Strength Flexall with ultrasound therapy.”
- Cyndy Glynn, director of marketing, Gebauer Company (makers of Pain Ease, Instant Ice, and Spray and Stretch), Cleveland (www.gebauer.com): “One of the biggest misconceptions regarding Gebauer’s Spray and Stretch is that it is too expensive. Spray and Stretch can be used between multiple patients, and has the potential to eliminate the source of pain through muscle manipulation and the spray and stretch technique—ultimately saving on residual remedies to control pain from unknown sources.”
- Justin Toups, marketing manager, China-Gel (makers of CHINA-GEL), Arlington Heights, Ill (www.chinagel.com): “It can be a source of revenue to supplement treatment income, but the issue is much broader. It puts a tangible item in the patient’s hands that becomes an extension of the therapist’s services.” —GT
Greg Thompson is a contributing writer for Rehab Management. For more information, contact .