by Jenna Coe, OTR, MOT, C/NDT, and Tiffany Weiser, PT, DPT, C/NDT
The human body is an amazing organism that allows itself to adapt and compensate for an individual’s soft tissue restrictions and impairments to achieve desired functional tasks. It is inevitable that these adaptations and compensations will eventually lead to pain and injury. These adaptations and compensations are seen in every population from the healthy weight-lifting athlete, to the older, more feeble individual living a sedentary lifestyle, to a child who presents with a neurological dysfunction. No matter what the individual circumstances, the body will learn secondary stabilization strategies and use abnormal movement patterns to achieve its desired tasks, creating soft tissue breakdown and, ultimately, pain. It is often not until the body is screaming in pain that the individual seeks medical attention to appropriately address these poor movement patterns. The use of various modalities and technologies can be very useful to us as medical professionals to effectively address our patients’ impairments to allow them to return to safer and improved movement patterns that will ultimately reduce and eliminate pain levels.
Members of the clinical staff at All Care Therapies of Georgetown, Georgetown, Texas, are challenged to manage pain levels among an expansive scope of individuals who seek treatment at the clinic each day. Among the All Care clientele are individuals ranging from birth throughout the lifespan. Diagnoses are as varied as the ages of the clientele themselves and include neurological conditions, post-stroke, orthopedic, postsurgical, and degenerative diseases.
The Pain-Free Plan
Regardless of age or diagnosis, the goals among the clinic’s patients typically are the same: Get back to living life fully and pain-free, as quickly as possible. To ensure patients have treatment sessions as unique as they are, the goals for treatment are never to just “reduce pain,” but rather to reduce pain during activities that are important to them. For example, if Mrs Smith loves to play basketball, her goal may be to participate in a game of basketball for more than 10 minutes. If Mr Jones works for UPS, his goal may be to lift an object greater than 20 pounds overhead. During each session, therapists and clients sit down together and look at their goals, lifestyle, work, and/or school schedules to determine which modalities will work best with their current treatment plan.
Make Every Purchase Count
As a relatively new practice that has been in operation less than 2 years, all staff members must work within significant budget and space constraints. When selecting modalities for purchase, therapists have to analyze each piece of equipment and weigh the pros and cons. With each purchase the clinic’s executive team evaluates the proven success rate of each piece of equipment in addition to analyzing cost of the equipment, how much space it uses, and number of clients who will benefit from its use. In a given month, the clinic tries to spend no more than $400 on equipment needs. This includes expenses related to maintaining equipment and disposable expenses related to modality use. This limited budget requires an extremely selective purchase process.
When making a purchase, the decision-making team relies heavily on personal experience or the experience of trusted colleagues. When the practice first opened, many of the first purchases were equipment the founders knew were used successfully from previous work experiences. With the business now established, the current purchase process is informed by published research, information gathered by reading review sites, and consultation with trusted colleagues who have experience with each modality’s use.
The substantial variety of modalities currently available well suits the practice and its needs. Although ever-changing, the following is a review of modalities currently used within All Care and the populations for whom they are most effective:
E-Stim: Electrical stimulation, or as it is more commonly referred to, e-stim, is a very popular modality within the clinic due to its variety of uses. E-stim is a form of electrical current that is used to stimulate and affect the tissues of the body. Depending on the settings used, e-stim can be effective in stimulating the muscles to contract to help with muscle spasms, weakness, or atrophy, increasing blood flow to speed healing and reduce inflammation, or stimulating tissue cells to speed up the healing process after an incision or injury. Clinical staff members prefer devices that allow for multiple leads to be attached so more than one site can be treated at a time. Also preferred are devices that are portable and allow patients to complete functional activities during treatment when appropriate. On occasion, patients who have been well trained in the use of an e-stim device may be able to use the device at home to maximize outcomes once they demonstrate proficiency.
Iontophoresis: Similar to e-stim, therapists at the clinic use iontophoresis as a form of pain management. Iontophoresis uses an electrical current to administer different ionic medical compounds to the tissues of the body. These medical compounds can be used to obtain a variety of different results, including reducing inflammation, reducing calcium deposits, reducing scar tissue build-up, decreasing muscle spasms, and decreasing edema. Dexamethasone is primarily used at this clinic to reduce inflammation and pain in clients. Again, therapists prefer an iontophoresis machine with multiple leads to allow for different areas to receive treatment at the same time.
Ultrasound: Another tool used by clinical staff in the reduction of patients’ pain symptoms is ultrasound, which works through a vibration of crystals within the ultrasound head, causing a vibration of the local tissue. This vibration creates a deep heating within the tissue, which the patient usually does not feel at all. This heating effect can help relax tissue, increase blood flow, break down scar tissue, and increase tissue extensibility. The increase in blood flow can also help reduce swelling and inflammation. All Care’s clinical staff members prefer a device that allows for adjustable intensity and a portable device that allows the device to be easily moved to and from different rooms.
TENS: Typically used for an at-home pain reliever, the TENS unit is a very useful modality that is easy for patients to independently use and regulate. It is used for patients who suffer from chronic pain by providing a stimulus that interferes with the pain signal to the brain. Allowing patients to experience pain-free movements reduces unwanted abnormal movement patterns that cause muscle guarding and neural tension.
Therapeutic taping: This can be a very useful adjunct to pain management therapy. It is used frequently with all of the clinic’s patients, from children who are affected by neurological dysfunctions to athletes. Taping can be used to help facilitate musculature, facilitate proper positioning for good movement patterns, reduce overtension that contributes to increased pain levels, and inhibit musculature. The bonus to therapeutic taping is that it can last for days after a treatment session, providing the patient with continual input.
Hot and cold packs: These are basic modalities that can offer a lot of benefits. Heat allows for muscle elongation to get desired range within the limited tissue that is causing an overtension to the affected joint. Moist heat increases local circulation and relaxes muscles and soft tissue. It is often used as a preliminary modality for further treatment. Ice packs and ice massage are used in acute injuries to assist in pain relief by reducing inflammation and swelling.
Therapeutic laser: Although not currently used at our clinic, therapeutic lasers and topical analgesics may also be used to assist with pain management in certain patient populations. Therapeutic lasers utilize wavelengths of light to interact with tissues and help with the healing process. It is designed to eliminate pain and swelling and also to reduce muscle spasms. Topical analgesics relieve pain at the surface nerve level of the skin, rather than working at the muscle level, providing temporary pain relief.
Overall, All Care has found its pain management programs to be rather successful. Most patients report success and, when the appropriate modalities are combined with a comprehensive treatment plan, patients report reduced pain levels and increased functional outcomes within a few sessions. Patients who are postsurgical also report reduced dependence on prescription pain medications to manage pain symptoms after surgery.
Moving forward, the physical therapists at All Care Therapies of Georgetown are in the process of becoming certified in dry needling to advance the practice’s pain management program. The goal is to offer a well-rounded program that utilizes a variety of tools and solutions to meet each patient’s needs. Dry needling will be an interesting component to add because it addresses the peripheral noxious input that contributes to chronic pain symptoms that will be complementary to other traditional modalities used. RM
Jenna Coe, OTR, MOT, C/NDT, attended Texas State University and the University of Texas Health Science Center in San Antonio, where she received her Bachelor of Science in Health Care Sciences and Master of Occupational Therapy in 2010. Coe received her Neurodevelopmental Treatment (NDT) Certification in 2012 and has experience in pediatrics, adults, and orthopedics in the clinical, hospital, skilled nursing facilities, and home health settings.
Tiffany Weiser, PT, DPT, C/NDT, attended Duquesne University in Pittsburgh, where she earned her Doctorate of Physical Therapy in 2010. She became certified in Neurodevelopmental Treatment (NDT) in 2014. Weiser’s primary focus has been in pediatrics, and she has worked in a variety of specialized pediatric settings including children’s hospitals, private practice, school settings, and early intervention. Her additional experiences include working in nursing homes and adult outpatient orthopedics. For more information, contact [email protected].