by Sean Vanin, DPT
When contractors approach a project, they think about what their goal is, what needs to be done, and what tools and supplies are needed to complete it. They don’t arbitrarily select tools; there is a specific function each tool has, and the contractor has to know how to use it. In the same way, when physical therapists are considering what modalities to use, the goals for the treatment need to be considered: Is the modality for pain relief, edema, or range of motion (ROM)? Will this be the only treatment, or will it be used with exercise or manual therapies? It is important to understand the therapist’s toolbox. Looking at the research is a good place to start.
In most research studies, modalities are rarely used by themselves, but rather are used in conjunction with other therapies. However, this fact that modalities are not usually studied as the sole treatment makes it difficult to isolate the effectiveness of the modality. In addition, there are few, if any, standardized parameters for modalities and fewer studies that look at effective dosages. So what is a physical therapist to do? This is where the American Physical Therapy Association’s (APTA) “Components of Evidence-Based Practice” become relevant. A combination of best available evidence, clinical knowledge and skills, and patient’s wants and needs are used to determine best use of these tools.1
At The Physical Therapy and Wellness Institute (PTW) in Pennsylvania’s Montgomery and Bucks Counties, the patient is the start point of the decision. Therapists ask, “What would best help the patient accomplish his or her goals?” rather than ask, “How can I use this modality on this patient?” The answer to the first question is based on what is known from experience and from studying the research literature. What follows is by no means exhaustive, but a brief review of research trends for different pain management tools.
Modalities Move In
Possibly the most accessible tool is cyro- or thermotherapy. These are affordable and easy to use in comparison to other modalities. In theory, the temperature change can affect tissue blood flow and nerve conduction velocity. It is extremely easy to safely instruct a patient in home use of these modalities. However, the tissue temperature changes can be superficial, so if the target tissue is deep, other modalities like ultrasound (US) might be more effective. US’s ability to send sound waves into deeper tissues makes it effective as a heating modality. There is some evidence showing benefits of US for treatment of shoulder calcific tendinitis.2 Researchers noted successful US treatment had increased treatment times allowing for increased energy absorption by target tissues. US is also recommended for decreasing neck pain.3
Another deep tissue modality is low-level laser therapy (LLLT). In 2010, Tumility et al did a systematic review of the literature, citing mixed results.4 However, in 2014, Haslerud et al looked specifically at LLLT for shoulder tendinopathy and reported more positive results.5 The latter study evaluated studies using parameters for LLLT by the World Association for Laser Therapy (WALT).6 These common parameters benefit researchers as it gives more accurate comparisons between treatments and studies. As a consumer of evidence, this gives us easier application of evidence to clinical practice.
Transcutaneous electrical nerve stimulation (TENS) is not as consistent, with varying parameters and dosages seen in the literature. This makes meta-analyses and systematic reviews difficult to compare. This could be why some reviews have a hard time making statements on TENS effectiveness over other modalities or treatments.7 However, there is evidence that suggests using TENS can reduce analgesic pain medication use after surgical procedures.8
Similar to cryo- and thermotherapy, topical analgesics (TAs) are a good way to give patients some control over pain. TAs give the ability to provide local pain relief without systemic side effects of oral medications. Decreased systemic side effects may also increase patient compliance. Increased compliance will lead to better pain management and allow for more movement and exercise at home. The catch is, some medicated TAs (ibuprofen, diclofenac, etc) may require a prescription for use, making collaboration with the patient’s physician necessary. When it comes to research, the ability to use a placebo TA allows for stronger study structures, allowing for more accurate statements on TA effectiveness. TAs containing NSAIDs have been researched on musculoskeletal injuries and have been shown to be better than placebo and as effective as oral NSAIDs.9,10 Studies looking at lidocaine have used the medication on neuropathic pain and allodynia. These have shown TAs including lidocaine are more effective than placebo for these conditions.9 TAs with menthol as the active ingredient are being studied with small group sizes, making more research necessary. Despite this, the current evidence is positive for TAs with menthol when compared to placebo in patients with knee arthritis.11
Evidence Points the Way
How is one supposed to apply this knowledge to modality use in the clinic? At PTW, we use modalities for a range of our outpatient orthopedic patients. Much like treatment-based classification for treatment of low back pain, every patient presents a little differently, requiring different approaches. A patient that reports pain and stiffness in the shoulder or neck might receive US to heat deep target tissues. An acute, swollen ankle sprain might receive a treatment with a cold vasopneumatic device. TENS would be used during acute pain episodes after surgery. We adjust our modality tool use to fit the patient presentation. Our selection is dependent on the “Components of Evidence-Based Practice” set out by the APTA, so we stay on top of the latest research to know what to offer.
Tools to Go: Hot/Cold and TENS
Efficacy in the clinic is important, but some of these modalities are easier to adjust to home pain management than others. The obvious first choice is hot and cold packs. They can be bought or made at home with household items: freezer bags with alcohol/water mixture for cold packs and a microwaved wet towel for a moist hot pack. Within the last few years, home TENS units have become much more common and affordable. Depending on insurance, patients may have to pay little or nothing out of pocket to get “prescription-strength” TENS units. Finally, TAs are commonly used at home and can be used before or after therapy sessions.
Educating the Patient
The key for therapists with any use of home modalities is education. It may seem obvious to therapists, but tell the patient they shouldn’t sleep with a hot pack on their neck. How many times has anyone had a patient come in with a burn because they fell asleep on the recliner with their hot pack turned on? We should also remind patients, cold packs and ice can burn skin as much as hot packs. Left on too long, cold packs can also cause neuralgia. It becomes a safety issue when a patient tries to use modalities from the clinic at home without the guidance of our expertise.
If a patient at PTW orders a home TENS unit, we either have the unit delivered to the clinic or have the patient bring it in. That way we can go over proper and safe use and troubleshoot any problems or patient concerns. Safety at home is as important as safety in the clinic, and if the patient is using the modality at our suggestion, it leaves us potentially liable if something goes wrong.
All the information, suggestions, and options can seem overwhelming; the place to start is to figure out the needs of the patient and adjust accordingly. These adjustments help to manage pain but also let the patient know we are adjusting care to fit their needs. To patients, this shows compassion for their pain, knowledge and expertise in our field, and flexibility in providing care. It builds confidence and trust. It is easier to get a patient with a frozen shoulder to do stretches knowing they will be receiving pain relief with heat and TENS afterward. At PTW, part of the mission statement is to “exceed expectations” of the practice’s patients. The staff pursues that mission by building trust and community between patients and physical therapy providers. Staying on top as new research and technologies come out not only improves pain management for our patients, but shows compassion and ability. As therapists know, this is the reason for bridging evidence into practice: caring for patients by using the best available tools, knowledge, and research. RM
Sean Vanin, DPT, is clinical supervisor at the Physical Therapy and Wellness Institute in the Quakertown, Pa, location. He received his Bachelor’s degree in Dance from Muhlenberg College, where he performed at local, regional, and national levels. Vanin received his DPT from Drexel University. He specializes in industrial rehab and dance physical therapy and is an APTA member. For more information, contact RehabEditor@medqor.com.
1. Gardner K. Evidence-Based Practice & Research. APTA. Available at: http://www.apta.org/EvidenceResearch/.
2. Alexander L, Gilman D, Brown D, Brown J, Houghton P. Exposure to low amounts of ultrasound energy does not improve soft tissue shoulder pathology: a systematic review. Physical Therapy. 2010;90(1):14-25.
3. Blanpied P, Gross A, Ellior J, et al. Neck pain: clinical practice guideline revision 2017. J Orthoped Sports Phys Ther. 2017;47(7).
4. Tumilty S, Munn J, McDonough S, Hurley D, Basford J, Baxter G. Low level laser treatment of tendinopathy: a systematic review with meta-analysis. Photomed Laser Surg. 2010;28(1):3-16.
5. Haslerud S, Magnussen L, Joensen J, Lopes-Martins R, Bjordal J. The efficacy of low-level laser therapy for shoulder tendinopathy: a systematic review and meta-analysis of randomized controlled trials. Physiother Res Intern. 2014;20(2):108-125.
6. Dosage Recommendations. World Association for Laser Therapy. 2010. Available at: https://waltza.co.za/documentation-links/recommendations/dosage-recommendations/.
7. Brosseau L, Milne S, Robinson V. Efficacy of the transcutaneous electrical nerve stimulation for the treatment of chronic low back pain: a meta-analysis. Spine. 2002;27(6):596-603.
8. Bjordal J, Johnson M, Ljunggreen A. Transcutaneous electrical nerve stimulation (TENS) can reduce postoperative analgesic consumption. A meta-analysis with assessment of optimal treatment parameters for postoperative pain. Europ J Pain. 2003;7(2):181-188.
9. Argoff C. Topical analgesics in the management of acute and chronic pain. Mayo Clin Proceed. 2013;88(2):195-205.
10. Jorge L, Feres C, Teles V. Topical preparations for pain relief: efficacy and patient adherence. J Pain Res. 2010;11:11-24.
11. Topp R, Brosky J, Pieschel D. The effect of either topical menthol or a placebo on functioning and knee pain among patients with knee OA. J Geriatr Phys Ther. 2012;35(2):92-99.