Rehab patients tend to groan when they see physical therapists coming. After all, the old PT (pain and torture) cliche is not far from the truth. Particularly over the last decade, the protocol for pain management has often been more pain—at least in the eyes of most patients, who must now get up and get moving.
Nowadays, bed rest is usually avoided, if possible, and some therapists admit this relatively new paradigm can be a shock to older patients. Mark Christensen, DPT, agrees that pain is increasingly being controlled through exercise, in addition to familiar modalities such as ultrasound, electrical stimulation, and traction. As patients perceive it, the method is to heap on more pain to get rid of pain.
As a therapist treating patients at Rebound Orthopedic Physical Therapy in Portland, Ore, Christensen says he has gradually come to embrace the wisdom of exercise over passive modalities. “Current research is starting to show that exercise is better for pain management,” acknowledges Christensen.
Andrea Hughbanks, DPT, founder of Everybody Physical Therapy, has seen a shift toward greater exercise frequency and duration for a wide range of pain sufferers. Beyond the walls of her Portland, Ore-based clinic, patients are doing far more rehab exercises at home, a shift partly driven by insurance, but also by research that confirms the efficacy of home-based rehab.
For patients at Everybody, a 3-day-a-week clinic stint is now unusual, with one or two weekly trips to the clinic much more common. Without the watchful eyes of a therapist, exercise compliance is a worry. Hughbanks acknowledges the concern but is quick to point out that outpatients coming in for pain management/rehab therapy typically have the right mind-set. “They are going to do whatever it takes,” says Hughbanks, who began practicing in 2001. “We give the tools to the patient—whether home exercises, ice packs, or electrical stimulation units such as TENS (transcutaneous electrical nerve stimulation) for pain control—and they follow through in the home.”
In the hospital setting, patients with added comorbidities are less likely to zealously adhere to an exercise program, and Hughbanks says these people naturally require more oversight. Other patients are seeking to avoid heavy painkillers. “Pain medications can have some pretty significant side effects,” says Hughbanks. “Most of my patients want to get off medications and even forego them altogether. Even with long-term use of ibuprofen, you are looking at liver damage and kidney damage, not to mention irritation to the stomach. And some of the more aggressive drugs can certainly be addictive.”
While therapists are usually not allowed to give medication advice, Hughbanks says they can and should recommend active discussions with physicians, specifically when it comes to pain. “Pain medication is helpful in the beginning so that patients can tolerate some of the things we’re asking them to do, such as the manual therapy techniques,” adds Hughbanks. “And hopefully they can decrease that pain medication as we move forward with therapy.”
At Select Physical Therapy in Las Vegas, Andrea Avruskin, PT, DPT, ATC, LAT, agrees that the active approach has unquestionably garnered more favor in recent years. “Today, we realize that inactivity itself may contribute to prolonged chronic pain,” says Avruskin, a staff therapist at Select. “Unless someone has a recent, acute injury that requires specific modalities, we are much less likely to do passive modalities. Instead, we assess deficiencies in flexibility, strength, endurance, and independence for a home program—and we evaluate for edema.”
In practice, Avruskin finds that patients who are able to restore stability and range of motion are eventually able to reduce pain levels. While acknowledging that effective pharmaceuticals have their place, Avruskin hopes to see new pain medications that do a better job of limiting sleepiness and addiction. After all, groggy and medication-dependent patients are less likely to zealously adhere to exercise programs.
As to the question of when those exercise programs should begin, Avruskin believes a common misconception is that therapists must wait until the pain subsides. Patients may want to wait, but a tough rehab approach may be what is best for patients. “It’s often hard for empathetic therapists to ask suffering patients to stretch and strengthen the very area that is causing pain,” laments Avruskin. “With experience, however, PTs realize that restoring mobility and stability can be the most important step in reducing chronic pain.”
MAKING THE MOST OF MODALITIES
Therapists typically use heat to reduce muscle guarding or spasms—a practice that can ready a body part for motion and strength training. Meanwhile, cold modalities are useful for edema, inflammation, or simply numbing an area. Avruskin and many therapists choose to finish the majority of treatments by applying cryotherapy to reduce pain and prevent further swelling from newly gained range of motion.
While some patients zealously believe that actively switching from cold to heat and back again is beneficial, Avruskin is skeptical. “The benefits of contrast therapy are anecdotal at best, unverified by controlled studies,” says the Las Vegas-based therapist who has treated dozens of Cirque du Soleil acrobats. “Contrast therapy is traditionally used to reduce edema. However, as many athletes can tell you, a contrast bath for a sprained ankle is not done for pain relief. In fact, the discomfort of alternating between ice and heat is intense.
Nevertheless, I have had numerous patients tell me they use contrast heat and cold at home on neck or back injuries, and they felt it was of some symptomatic benefit. I rarely use contrast therapy in the outpatient clinic. I am more inclined to use it for athletic injuries in an athletic training room setting, but even that is rare.”
Mark Christensen agrees that heat and/or contrast therapy yields vascular dilation at a superficial level. Like Avruskin, he prefers cold to reduce swelling.
Avruskin points out that determining how, when, and what modality to use is ultimately a function of each therapist’s judgement, experience, and training. Whether the treatment is to reduce pain, swelling, or stiffness, an almost universal goal boils down to bringing patients to a point at which they can tolerate strengthening and stretching.
While he does not use topical analgesics, Christensen acknowledges that topicals may help people feel better and, as a result, may help them do more exercise. “I do use hydrotherapy and whirlpool treatment, which have some healing and pain reduction properties,” says Christensen. “I also use electrical stimulation for pain control and/or muscle reeducation. TENS would be more for pain control, but I also use an interferential current for pain control and biphasic for muscle reeducation.”
Andrea Hughbanks uses TENS to combat the sedative effects of pharmaceuticals, and to deliver pain relief to patients who would rather lay off of pills. “I find that home TENS units are really helpful, especially for patients who can’t tolerate pain medication and don’t want to take pain medication,” says Hughbanks. “Patients can even use TENS at work because another side effect of a lot of the pain medications is that they are heavy duty, and you really can’t focus and be productive. We also still use ultrasound, and every once in a while we use iontophoresis.”
Compression modalities such as garments and bandages are routinely used by therapists to treat lymphedema, but in the realm of pain management compression usually serves a different purpose. “Compression is one component of controlling pain and swelling from an acute injury such as a sprain or strain,” confirms Christensen. “As for use in chronic conditions such as fibromyalgia, I don’t know of any therapeutic benefits.”
Whether patients receive compression, a TENS unit, or a full exercise program, Hughbanks always sends patients home with written instructions that describe all activities, repetitions, sets, and exercise frequency. “We use [a software program that features] different types of software within that program for pelvic floor exercises and orthopedics,” says Hughbanks. “You can look it up by the body part and add refinements depending on whether you are describing stretching, strengthening, or proprioception. You can even e-mail these to patients. I also have simple flyers in a drawer.”
Whatever treatment you prefer, Christensen cautions that therapists should never presume that if one thing works on a patient, it will necessarily work on another. “Therapists think that everyone has the same pain threshold, but the pain tolerance for one person may be quite different from another person,” says Christensen. “A person may walk in and say he is in excruciating pain, but if it could be measured in some way, you may find that another person may have the same amount of pain but label it differently. A therapist might think, ‘Well, this person had ultrasound and it worked, so this other patient will respond to ultrasound.'”
When in doubt, Avruskin seeks to inspire confidence in patients with a good dose of honesty. Many PTs may believe that patients are too focused on their pain. In this case, don’t oversell the benefits of therapy, but instead recite the potential benefits as you see them. “Try saying, ‘It’s not definite that physical therapy can get rid of your pain, but if any of your pain is being caused by weakness, stiffness, swelling, or misalignment, physical therapy can improve all of those things,'” says Avruskin. “Ask patients to give it a few weeks to start feeling results. Honesty, stated in compassionate and cooperative terms, will usually garner better results than being dismissive.”
Greg Thompson is a contributing writer for Rehab Management. For additional information, contact .