Tom Watson, DPT, MED, DAAPM, observes the patient perform an active-assisted stretch/exercise in a supine position, gravity minimized, to increase flexion of his right shoulder. This increases the patient’s active range of motion and helps him progress to a seated exercise doing the same technique.

Many patients endure pain silently, but they don't always have to. In a special message on pain as an epidemic, Kathryn Weiner, the former executive director of the American Academy of Pain Management, Sonora, Calif, suggests that pain is undertreated in the United States.¹ More than four out of 10 people who suffer moderate to severe pain report they were unable to find adequate pain relief.¹ With 75 million US adults estimated to be living with pain—50 million of them with chronic pain—this indicates that many patients are suffering.¹ Over the past 2 decades, there has been growing awareness of this epidemic. The Oregon Pain Management Commission (OPMC) was created in statute in 2001 and actually started in 2002. The OPMC's purpose was to investigate the undertreatment of pain in Oregon and report barriers to the Governor and legislature.

"Chronic unrelieved pain brings about a lot of human suffering and lost productivity. In 1999, we did have support groups and resources for patients with pain, but we now seek to increase pain-management awareness among the public, policymakers, and the medical community," says Tom Watson, DPT, MED, DAAPM, of Living Well Therapy PC, Bend, Ore, and a member of the OPMC.

The group's stated mission is to improve pain management. Watson notes that since the early 1980s, understanding of pain and associated neurobiology has increased. "Better understanding of pain has led to better understanding of the interventional techniques that may be done peripherally or internally," Watson says.

Approximately 50% of Living Well's patients come to the practice with some type of chronic pain. Their diagnoses vary, but Watson's goal is to have an 85% improvement within the first eight visits. Naturally, some patients improve more quickly, while others require more time, but the goal works for Watson.

He uses a variety of techniques to achieve it, often starting with manual therapy and exercise and incorporating other modalities as necessary, including cold laser, electrical stimulation, and interferential current therapy. Methods are tailored to the patient and the diagnoses, and alterations are made if something doesn't work.

"There is no one way to manage pain," Watson says. A multidisciplinary approach can provide the best management, treating psychological issues along with the physical. The OPMC has established an educational program for all licensed health care professionals in the state of Oregon, which is now required through legislation.

Watson expects to see more such organizations coalesce as awareness about the causes and costs of pain continues to increase. "Constant pain costs about $40 billion per year to treat and is the number one reason for absence at work. But with the correct intervention of pain-management techniques, we can improve a patient's quality of life, independence, and health expenses and help them get back to work," Watson says.

LIVING WELL WITH PAIN

Watson and his colleague, Erik Zamboni, DPT, CSCS (yes, he is related to that Zamboni—according to Watson, Erik Zamboni is the great nephew of Frank Zamboni, the inventor of the ice resurfacer), see between 50 and 70 patients per week at Living Well's two offices. The practice has a second office open Monday, Wednesday, and Friday mornings in Sunriver, Ore.

Zamboni founded Living Well in July 2004; Watson joined the practice in May 2005 (a receptionist and office administrator round out the full-time staff). "We have the experience in treating pain conditions that are more difficult to diagnose," Watson says.

Patients can suffer pain for a variety of reasons. Common diagnoses include postsurgical rehabilitation, temporomandibular joint disorders, fibromyalgia, trigeminal neuralgia, and headaches. Watson estimates about 50% of pain patients come in for postsurgical rehabilitation—often shoulders, knees, hips, and ankles—and 20% with TMJD.

Patients often come to Watson with a diagnosis from another physician, but in some instances, they may be undiagnosed. "Internists can rule out internal organ problems, but sometimes tests have been unable to determine the cause of the pain. Based on my 34 years of experience, I often have a good idea of the source," Watson says. He is comfortable determining and managing orthopedic, neurological, and visceral diagnoses that do not involve major pathology, do not require surgery, and are not life-threatening. In some instances, Watson has even corrected a misdiagnosis. "I've had three patients diagnosed with TMJ disorder that actually had trigeminal neuralgia," Watson says.

WORKING THROUGH THE PAIN

Whatever the diagnosis, it will naturally guide treatment. For orthopedic patients, Watson prefers to begin with manual therapy and exercise. "We usually do that first because we can then move on to appropriately dosed exercise to strengthen, lubricate, and inhibit pain in the joint," Watson says.

Watson suggests that manual physical therapy works well because it affects the mechano-receptors in the muscles and tendons, permitting an increased range of motion with less pain. The technique involves five grades of therapist force: one represents an almost imperceptible motion, and five stands for a high-velocity, low amplitude, short manipulation. The force depends on the patient's specifics.

Watson also practices primal reflex release therapy, or PRRT, a technique developed by John Iams, PT, SuperSpine Inc, San Diego. Iams theorizes that primal reflexes, such as the startle reflex, are key to chronic pain and that the manipulation of certain trigger areas, often with a finger or reflex hammer, can relieve the pain. Watson has found the technique to be highly efficacious. "The techniques Iams has developed are extremely effective at inhibiting pain and muscle spasms without the manipulations we perform in manual therapy," Watson says.

To complement his use of these methods, Watson employs two topical pain-relief agents that are not used during therapy but are sent home with patients: ALCiS, which is available in 30-day, 60-day, and 90-day packages; and Biofreeze, which comes in a tube, pump, roller, and spray. Watson also uses the Spray and Stretch technique, which incorporates a vapocoolant, such as Gebauer's Spray and Stretch, into manual therapy. Watson will spray the agent onto the patient's trigger points to inhibit pain during manipulation. The agent is recommended for use in the management of myofascial pain, restricted motion, muscle spasm, and minor sports injuries.

Watson performs a grade 2–3 mobilization, distal glide, to increase the range of motion in the patient’s left shoulder. This mobilization decreases the patient’s pain and improves the functional mobility of his right shoulder.

LIGHTENING THE LOAD

When these methods are not sufficient, Watson will turn to other techniques, such as cold laser and electrical stimulation, including microcurrent electrical therapy (MET), transcutaneous electrical nerve stimulation (TENS), and interferential current therapy. "My laser is my best and most efficient tool and does fantastic things when you can think of nothing else," Watson says.

Watson has been using cold laser or low-level laser therapy since the early 1980s. "Cold laser was first introduced in the late 1970s and approved for carpal tunnel syndrome in 1994," Watson says. Erchonia Medical, McKinney, Tex, received FDA clearance for cold laser use as an adjunctive to pain therapy in January 2002.

"The method has been used in more than 260 randomly controlled, scientific, and double-blind studies, which have shown it reduces inflammation, swelling, and pain, and can actually stimulate both soft tissue and bone healing," Watson says. The method has shown no adverse side effects and is contraindicated in the eyes, over the pregnant uterus, and thyroid.

Watson estimates that there are about 12 companies in the market and that lasers are typically available with wavelengths between 630 nm and 1000 nm. "Anything between 600 nm and 1000 nm is considered to be a cold-level or low-level laser," Watson says.

LED, or light-emitting diode, lasers will cost less than true lasers, which can run in the $10,000 to $15,000 range, according to Watson, but they work more slowly. "The LED equipment can take twice as long to produce the same result as a true laser. It can be used effectively but is a bit like bringing a knife to a gunfight," Watson compares.

He prefers to use 830-nm lasers but has changed his methodology over time, incorporating greater variability in the laser settings to better suit patients. "You can adjust between milliwatts and joules. Depending on the chronicity of the pain, the thickness of the tissue, and the patient's responsiveness, I will change the setting without going beyond the manufacturers' recommendations," Watson says.

For patients with no initial response, Watson will increase the setting; for those with any discomfort, he will decrease it. "The patient should feel nothing. So if they have any strange sensations, it could indicate the need for a lower setting," Watson says.

SOOTHING STIMULI

Methods of electrical stimulation also feature different frequency settings. MET attempts to normalize electrical activity of the neurological system by creating harmonic resonance among the electrons in the affected region and the body in general. Devices can run $5,000 to $10,000, suggests Watson, who uses the Alpha-Stim 100 from Electromedical Products International Inc, Mineral Wells, Tex. The device is preset at 0.5 Hz, the frequency he prefers. Additional settings include 1.5 Hz and 100 Hz.

No adverse side effects have been reported. "This device can be used safely transcranially in patients," Watson says. Transcranial use can help patients achieve levels three and four of sleep, the levels in which human growth hormone and other systems are replenished. "Many pain patients miss this sleep," Watson says.

TENS is another method of electrical stimulation used in pain management and, according to Watson, is one of the most common. TENS frequencies range between 1 Hz and 160 Hz. The method works by stimulating nerve fibers through the skin using electrical pulses. Users can vary the pulse frequency, intensity, and duration. The results produced by TENS are similarly varied with users showing great range in the time to onset of relief and its duration. TENS is more often recommended for mild to moderate pain rather than severe pain.

Interferential current therapy has been described by some as a deeper form of TENS. In fact, some equipment features both methods in one unit. Watson uses a Solaris device from Dynatronics Corp, Salt Lake City, which in addition to TENS and interferential current, also offers premodulated, Russian, biphasic, high-volt, and direct current.

The electrical impulses used in interferential current therapy are induced in the tissues using electrodes placed on the skin. The frequencies of each electrode can differ (and include fixed carrier frequencies of 4000 Hz and adjustable frequencies of 4001 Hz to 4400 Hz) but will meet within the body, where their combined effect will be to reduce pain, either by blocking the transmission of pain signals or by stimulating the release of endorphins. The higher frequency permits deeper penetration.

A WORLD OF PAIN

"These methods operate on the principle that a low-amplified stimulus can promote long-lasting changes to the body whereas a powerful but short stimulus produces a brief physiological response. They are effective pain-management tools, but they do not ‘cure' anything," Watson says. Their effects will also differ according to the patient and diagnosis. Whether the pain is acute or chronic will influence the course of treatment. "I predominantly use microcurrent therapy with chronic pain patients," Watson says.

The field of pain management is still developing, but Watson suggests that guidelines could be published this year. The American Pain Society and the American College of Physicians are working on the development of guidelines but have not yet released any details.

Watson works closely with professionals from other disciplines on the OPMC, which comprises 17 multidisciplinary appointed members and two ex officio legislators. Members have experience in acupuncture, chiropractic medicine, nursing, pharmacy, medicine (physicians and a physician assistant), exercise physiology, and psychology. The team not only gathers data to help create effective and humane pain policies but also acts as educators and advocates. Many commission members deliver comprehensive pain-management information to various professional associations. Watson, with a master's degree in education, does so regularly.

"Pain management is an ever-evolving field, and there are courses offered all the time," Watson says. Patients do not always have to suffer the pain; with the right treatment and commitment, they can improve. Watson notes that some patients with chronic pain may take 10 to 12 visits to experience relief, while some suffering acute pain can obtain relief in 2 or 3 weeks. Although his goal to have patients 85% improved within 8 weeks, the average patient requires only 5 or 6 weeks.

"The advent of laser therapy and new electrical stimulation methods such as microcurrent have moved to the forefront in pain therapy, while methods such as traditional massage have evolved into new techniques such as PRRT," Watson says. The improved methods have produced improved results.

Future trends in pain management may include nanoprobes, lisosomes, and higher-level treatments as well as more state commissions and guidelines to increase awareness and advocacy. Iontophoresis has become a widely used modality. A transdermal delivery system in which a substance bearing a charge is propelled through the skin by a low electrical current, this technique works through electrodes that are used to move the molecules of the medication through the skin.

With greater understanding of the mechanisms behind pain and how to treat it, fewer patients will find they have to endure the burden of chronic pain.

Renee DiIulio is a contributing writer for  Physical Therapy Products. For more information, contact .

Reference

1. Weiner K. Pain Issues: Pain Is An Epidemic. American Academy of Pain Management. Available at www.aapainmanage.org/aboutus/Media.php. Accessed May 14, 2007.