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| William Lee, PT, left, applies interferential stimulation to Anjoline Lopez’s knee to assist with pain management. |
Playing sports may pave the way to riches or provide simple joy, but when things go wrong, the walking wounded often hightail it to the PT. Injuries include lumbar strains (in those who play rotational sports such as golf or tennis), hip strains and adductor pulls (for runners and football players), shoulder impingement (football players who do lots of heavy lifting preparing for their sport), lateral epicondylitis (tennis players), and medial epicondylitis (golfers).
Therapists may first ensure that patients are able to manage independently by following the RICE principle, if possible—resting the injured region or tissue, icing, applying compression, and, if an extremity, elevating it to minimize swelling and inflammation. From there, a menu of modalities may aid in pain management. William Lee, PT, Outpatient Rehabilitation Services, Cedars-Sinai Medical Center, Los Angeles, then evaluates surrounding areas to assess for movement dysfunction that may be causing the pain cycle to continue—perhaps a joint or muscle pathology is present. He then tailors treatment plans for each patient that may include manual therapy techniques, therapeutic exercises, and modalities as needed during the course of the treatment plan. “We may use modalities, such as ultrasound, electrical stimulation, and hot/cold packs, to assist in breaking the pain cycle,” he says. “Hot/cold packs can be useful because they can assist the patients in self-management of their pain symptoms.
“Electrical stimulation can be useful,” Lee says. “It can potentially provide some temporary relief from the pain and assist in breaking the pain cycle at the neural level. And then from there, we can treat the patient’s joint or muscle impairment to assist in restoring normal function.”
Ultrasound may be used to assist with tissue healing if the area is small. Manual therapy or soft tissue mobilization techniques can be used in conjunction with the thermal effects from the ultrasound.
Heat therapy can be used for golfers and football players who sustain low back injuries while engaged in the activity. “Hot packs can assist in relaxing muscles that may be in spasm,” Lee says. “Cold therapy can be utilized if the main concern is pain. If it’s acute, we’ll use the cold therapy to break up the localized inflammation. Or if it’s just muscle spasm, muscle guarding, then we may rely more on the heat therapy to try to relax the muscles prior to doing any manual therapy techniques and exercises.”
Moist heat heating pads are used in the facility, and patients can easily substitute hot compresses at home to help relax affected muscles. “If they’re unable to take a rest from the activity, it may be a nice way of helping them cope on their own,” Lee says. In addition to weekend warriors, he often treats collegiate and high school athletes and club runners, who may have a hamstring spasm. Lee’s tool kit includes gel packs and crushed ice. He favors the crushed ice, swathed in layers of towels, because it is easier to shape around the joint or affected region and provides a more even distribution of cold.
Some patients skimp on an icing regimen, applying it only before bedtime, not realizing they may need its effects more often. “So they can control the inflammatory process that may be present, as well as trying to keep the pain level at a manageable level throughout the day—instead of having huge peaks and valleys,” Lee says, adding that he and his colleagues try to raise patients’ awareness about home-management techniques and following the instructions of their physician regarding the use of anti-inflammatories to complement their home-management regime.
Jana Richey, DPT, Marina del Rey, Calif-based Beyond Physical Therapy, sees a lot of rotator cuff injuries in weekend-warrior types who play basketball or volleyball. Their rotator cuff is likely not strong enough to stabilize the shoulder sufficiently to engage so fully in the activity, and/or there is a lack of flexibility in the shoulder girdle, creating imbalance and resulting in overuse injuries such as impingement and rotator cuff tendinitis. “I do a lot of hands-on work at the beginning, a lot of soft tissue mobilization, cross-friction massage to the tendons, and soft tissue work to the muscles themselves to disperse any spasms, break up any scar tissue, manage the inflammation by moving the stagnant fluid out, and promote blood flow,” Richey says. “In a rare case where I see somebody who is in such intense muscle spasm that they can’t handle soft tissue work, then I’ll go to ultrasound, or light, or a similar modality.”
She relies on ultrasound for tendinitis and muscle spasm, primarily if patients cannot tolerate soft tissue work well because of hypersensitivity. For muscle spasm, she usually uses a 50% pulse rate, around 1.2 watts per centimeter squared for about 10 minutes. For tendinitis, she generally uses a lower wattage—either .08 or 1.0 watt per centimeter squared, on a continuous pulse for about 10 minutes. Infrared light therapy units at her disposal vary from intense to more dispersed beams. Treatments are applied from 1 to 10 minutes, depending on the machine. Richey uses electrostimulation in acute cases, such as post-surgery, when a patient experiences a lot of pain and inflammation. While the treatment helps reduce swelling, some patients either love it or hate it, so she takes heed.
Richey uses cold gel packs to lessen pain and inflammation, especially in acute cases and usually at the end of treatment, but sometimes prefers ice. “If there is a small area, such as tendinitis, that I’ve really worked on manually and there is a very specific painful area, I’ll apply a direct piece of ice and do an ice massage,” she says.
Sometimes she combines modalities for best results. “In this case, I usually will use either ultrasound or light toward the beginning of the treatment, then e-stim at the end of the treatment, with ice,” she says. “I usually combine electrical stimulation with ice, if it’s for a pain management indication.”
Mark Stengler, ND, a licensed naturopathic physician, author, and lecturer at La Jolla Whole Health, his holistic clinic near San Diego, tells patients for the first 24 to 48 hours to ice the injury and follow with infrared therapy over the area of injury for 20 minutes, once or twice daily—which causes vasodilation and reduces inflammation. The technology is delivered through a pad resembling a standard heating pad, and he says infrared heat penetrates up to 2.36 inches under the skin, reaching muscles, blood vessels, lymphatic glands, and nerves. When indicated, Stengler uses naturopathic manipulation of the joints to improve mobility, and encourages patients to use hydrotherapy at home, alternating hot and cold compresses over the affected area. He refers patients to orthopedists, physiotherapy, or chiropractic services, when indicated.
His remedies may be unfamiliar to some. To help relieve stiffness and pain, Stengler uses a homeopathic pain gel made of a combination of remedies such as rhus tox, ruta, hypericum, and arnica. He also uses herbal anti-inflammatories such as boswellia and turmeric, which work, he says, like a natural COX-2 inhibitor, and bromelain, which reduces fibrin at the site of the injury. “For long-term inflammatory injuries, I like high-dose fish oil, particularly for joint problems,” he says. “For arthritis, take 2,000 to 3,000 mg combined EPA and DHA daily.” He often uses hyaluronic acid in supplement form to reduce pain and stiffness and aid in connective-tissue healing. (Stengler coauthored Prescription for Drug Alternatives, and writes the Bottom Line Natural Healing newsletter, www.drstengler.com.)
Weekend warriors and semiprofessional and pro athletes alike may potentially push themselves through the pain until they can push no more—which can be counterproductive. “Within pain theory, there is the idea that the pain signal can stay within our system even if the mechanical reason for the pain may have resolved,” Lee says. “So if you allow the pain to continue over a longer period of time, then you may still feel issues with the pain even though your body may be 70% or 80% healed.” The quicker the pain cycle can be broken, the faster people may regain normal function and movement patterns. If pain lingers for a long time, people may develop limps and altered movement patterns, which can promote other pain-causing mechanisms to arise as well, he says.
Judy O’Rourke is the associate editor of Rehab Management. For more information, contact .
Pilates for Pain Management
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by Moira Merrithew
There are several aspects to managing chronic pain, as well as pain in general. Chronic pain sufferers need a multifaceted approach in order to help them the best, including but not limited to physical or occupational therapy, ergonomic evaluations and adjustments, cardiovascular exercise, psychological intervention, and training/instruction in pain reduction techniques.
Musculoskeletal pain is not only extremely common, but leads to enormous costs to society in the form of diminished productivity, workers’ compensation and disability claims, and medical costs. The use of STOTT PILATES® Basic Principles is extremely beneficial in the acute rehabilitation phase, management of postrehabilitation clients, prevention of long-term dysfunction, and maximizing physical function for individuals with chronic problems. Physical therapists from all over the world are becoming much more familiar with these techniques and incorporating them into their practice.
The benefits of Pilates include the all-encompassing approach to the biomechanics of exercise, with a focus on core control (lumbopelvic, thoracic, scapulothoracic, and cervicothoracic), efficient alignment, muscular sequencing, and adjustments related to the need for stability or mobility. There is also a strong mind-body component, which enables clients to use motor learning principles to change the way that they move and exercise, with a resultant progressive change in the performance of activities of daily living and enjoyment.
The postural alignment element is possibly one of the most important aspects of regular participation in either private sessions or well-guided group sessions. The amount of time that individuals spend in passive slumped postures at a desk and the stress of the present economic environment are likely to increase the incidence of back and neck pain in the future. The versatility of Pilates exercises, and the sound biomechanical basis, makes these foundational exercises suitable for early rehabilitation as well as ongoing fitness and prevention of injury.
CASE STUDIES
Kim Dunleavy, PT, PhD, MOMT, OCS, uses STOTT PILATES extensively in her practice with postrehabilitation clients seeking help to work out safely and continue work started in outpatient settings. She sees clients at Equilibrium Pilates Studio in Bloomfield Hills, Mich, and is an instructor trainer for the rehabilitation courses for STOTT PILATES. She sees clients ranging from young individuals with sports injuries who wish to continue their progression and prevent future occurrences, such as a 14-year-old national level squash player with a recurrent hamstring tear to a 60-year-old physician who has spinal stenosis and lumbar laminectomies at L2-5 and nerve damage resulting in a foot drop and wishes to maintain his surgical practice, bike, and ski.
Both clients attend weekly private sessions and are able to participate in their desired sport/occupation without pain. The physician has been able to improve his alignment sufficiently and allow appropriate tissue challenges to increase the muscle firing and strength of the ankle muscles on the neurologically damaged side, with a resultant increase in muscle grade of the ankle and foot from a Grade II to a Grade IV. She also sees a number of clients with rheumatological disorders such as scleroderma, ankylosing spondylitis, rheumatoid arthritis, and lupus erythematosus who have benefited from being able to participate in group and private sessions safely without aggravating their pain. One client with ankylosing spondylitis has been attending Pilates sessions for 3 years on a weekly basis and has no low back pain, has improved her overall postural alignment, and has improved her balance reactions.
CATERING TO ADDITIONAL REHAB NEEDS
Other conditions that require long-term exercise to manage functional requirements such as degenerative disc disease, osteoarthritis, post-whiplash hypermobility, scoliosis, post-spinal surgery, and fibromyalgia all respond extremely well to graduated exercise programs using both gravity-reduced equipment and mat exercises with props such as balls, bands, and resistive circles. The exercises do need to be adapted for individual needs, but there are numerous options in the choreography and the choices of modifications. Individuals with pain or a musculoskeletal complaint are evaluated by the physical therapists working in the Pilates studio and obtain customized workout plans as well as being guided through their workouts and monitored carefully for compensatory patterns. The chronic alignment and muscular sequencing patterns associated with pain can cause secondary problems, and even an incident that seems simple, such as a toe fracture or minor knee pain, can cause adjustments that alter the joint alignment and cause other problems higher up in the lower extremity or trunk.
Clients with musculoskeletal problems benefit more from initial one-on-one sessions with qualified rehab professionals trained in Pilates, but can be seen in smaller groups with similar diagnoses. The attention to movement observation, cueing for optimal muscular activation and alignment, and teaching techniques for movement efficiency yields benefits that are dependent on the client changing their posture and movement patterns, and therefore consistent exercise will give more benefit than a few sessions.
HOW TO IMPLEMENT PILATES INTO YOUR PRACTICE
Pilates can be a very powerful pain reduction technique. Shannon Nicolette, PT, ATC, CPT, a STOTT PILATES instructor, offers these steps in working with clients.
Step 1: Redirect or refocus the client. Both mentally and physically, Pilates will do this whether you are in pain or feeling fine. We’ve all struggled through learning the intricacies of Pilates-style breathing, not to mention coordinating that with Pilates movements. This redirection (learning a new technique or skill) allows for a cerebral shift; the client’s perception switches off the pain and onto figuring out the “new” style of breathing (which, in turn, is a pain reduction technique. Meditative, focused breathing has been shown to reduce muscle spasms, guarding, and pain.)
Step 2: Oxygenating the blood. Learning how and when to breathe Pilates-style not only redirects the client’s mind, but also brings more oxygen throughout the body. And in addition to the new breathing pattern being a form of meditation, it also serves to deliver much needed oxygen to the areas of pain. This oxygenation serves to empower the muscles and reduce tension.
Step 3: Increasing blood flow. While the increase in total body oxygenation stimulates pain-reduction initially by shifting the client’s focus, much needed blood flow increases when the Pilates style breath is combined with the core muscle activation. This could mean something as simple as lying supine in alignment while drawing the abdominals in and up as you exhale. More blood flow means more nutrients delivered to working muscles and often means better general circulation, especially to the painful areas. These nutrients delivered via blood flow can aid in reducing muscle spasm and tension, thereby reducing pain. Additionally, the other “junk” that’s sitting around the client’s painful area (stagnant blood, prostaglandins, and excess fluid) gets flushed out, away from the area with enhanced/increased blood flow.
Step 4: Building strength! Much, though not all, of chronic pain is due to a coexistence of structural or functional malalignment with muscle weakness, inefficiency, and overuse. Proper head-neck and lumbopelvic alignment, as taught in Pilates, aids clients by first enhancing optimal blood flow, but second, by preparing the muscles for their most effective activation. Pilates is incredible at training clients how to activate all muscles more efficiently throughout the body. It is the concept of “neuro-muscular re-education,” as we say in the world of physical therapy. And it’s amazing to see it working in real life! Simply learning how to deactivate an overused muscle can be a paramount step toward pain reduction.
So the combination of several—if not all—of the basic principles feeds into how we successfully manage chronic pain and pain in general. And of course, the use of such modalities as ice, heat, and electric stimulation has its place in this pain reduction formula as well. “I have had excellent results, both personally and professionally by incorporating Pilates techniques,” Nicolette explains. “It is one of the most effective things we can do to gently slide our clients to the other side of pain.”
Simply learning and utilizing the proper breathing techniques while also increasing mind-body awareness through core strengthening and function are wonderful skills that will absolutely enrich our clients’ lives.
Moira Merrithew is the executive director of education of STOTT PILATES. For more information, go to www.stottpilates.com.
