treatingpain

by Gary Struble, PT, DPT, OCS

As Doctors of Physical Therapy, we continually seek to provide our patients with every available treatment and modality at our disposal. We must facilitate healing to be as quick and complete as possible.

While the cornerstones of our treatments are highly skilled manual physical therapy and therapeutic exercise, the utilization of modalities is an important exponent to the care we deliver. Popular modalities such as electrical stimulation, ultrasound, laser, therapeutic taping, thermal modalities, biofeedback, and virtual reality play vital roles as part of comprehensive treatment programs. Nevertheless, to evolve our practices and the care of our patients, we must address many patient factors and keep in touch with new and innovative modalities.

Modulating Pain and Facilitating Healing

Doctors of physical therapy deal with many factors of a patient, not only their injury. For instance, we inherently know if a patient is experiencing pain and guarding, or even if they sit in traffic for an hour and show up to their appointment in a stressed and agitated state of mind, they will likely not respond well to attempts at mobilization or neuromuscular training. That is one of the reasons why the application of modalities is just as important as the treatments themselves. We must consistently create an environment where treatments are as effective as possible and provide a superior standard of care. Ultimately, the right modalities have positive effects on the care we deliver—they are an exponent to outstanding hands-on care.

Physical therapists have many modalities directly at their fingertips; some are standards, some are newer innovative options. Performing a quad set is great. Performing it with visual and audible biofeedback regarding the strength of contraction is even better. Likewise, a static stretch can be facilitated by a moist hot pack and electrical stimulation, facilitating both patient relaxation and decreased guarding.

Similarly, to maximize their recovery potential, our patients often choose to participate in whole body cryotherapy, acupuncture, nutritional counseling, and/or meditation as adjuncts to their treatment. Physical therapists who have relationships with high-quality health and wellness partners offering these services give their patients immediate access to these options, which may accelerate their recovery.

Any opportunity to increase the body’s healing response, calm the nervous system, and improve the patient’s emotional state has a positive effect on treatment rendered. Patients who actively seek all available options to supplement their care often see superior results. For instance, we frequently hear patients report they feel their recovery was accelerated due to the innovative treatment of whole body cryotherapy, with reports of decreased pain and irritation, improved sleep, and increased energy and focus.

Product Resources

The following companies provide products for pain management:

Accelerated Care Plus
www.acplus.com

Amrex Electrotherapy Equipment
www.amrexusa.com

Ari-Med Pharmaceuticals
www.ari-med.com

Battle Creek Equipment Company
www.battlecreekequipment.com

China-Gel
www.chinagel.com

Dynatronics Corp
www.dynatronics.com

Everyway4all
www.everyway4all.com

Impact Cryotherapy
www.impactcryo.com

JTECH Medical
www.jtechmedical.com

LightForce Therapy Lasers by LiteCure LLC
www.litecure.com

Mettler Electronics
www.mettlerelectronics.com

OPTP
www.optp.com

Parker Laboratories
www.parkerlabs.com

PHS Medical by Pivotal Health Solutions
www.phsmedicalsolutions.com

Roscoe Medical/Compass Health Brands
www.roscoemedical.com

Sore No More
www.sorenomore.com

Southwest Technologies
www.elastogel.com

Understanding Innovative Modalities

Whole Body Cryotherapy

Whole body cryotherapy involves the use of nitrogen to rapidly cool the entire body in a cabin or cryosauna with temperatures as low as -250°F for 1 to 3 minutes. This is believed to accelerate healing and speed recovery, as well as lead to an enhanced athletic performance. Blood circulation is stimulated, activating your body’s hormone, immune, and nervous systems. Cryotherapy has gained global praise as a pain management tool and a recovery modality from muscle injuries through significantly alleviating inflammation after strenuous exercise by inducing an anti-inflammatory effect.

Similar to all cold thermal therapies, whole body cryotherapy has been noted by my patients for pain relief of tendinitis, sprains, arthritis pain, lower back pain, and recovery from strenuous physical endeavors. After sessions in our Impact Cryotherapy cryosauna, from Impact Cryotherapy, Atlanta, I have had patients ranging from Spartan race participants (innovative obstacle courses) and mixed martial artists to those with Lyme’s Disease and rheumatoid arthritis, report their recovery and comfort was accelerated by using whole body cryotherapy.

Therapeutic Laser

Therapeutic laser, or cold laser therapy, is a noninvasive procedure that utilizes specific wavelengths of light to interact with tissue. The therapy helps accelerate the healing process. It can be used on patients who suffer from a variety of acute and chronic conditions to help eliminate pain and swelling, reduce spasms, and increase functionality. Cold laser has few contraindications and is often an option where other modalities are ruled out. It is frequently combined with physical therapy routines to provide pain reduction and magnify results and an effective option when a high level of acute irritation and inflammation is present.

Companies that manufacture therapeutic laser for the PT market include LiteCure, New Castle, Del, which offers the LightForce FX therapy laser to provide custom treatment for a range of conditions. The company’s LightForce EXPi laser therapy system is a Class IV, solid state laser that can operate in continuous or pulsed mode and offer treatments based on skin type, body type, condition, and acuity. Another source is Pivotal Health Solutions, Watertown, SD, which provides its line of Apollo lasers as portable systems, and also as 2-channel desktop models. The desktop models can use two probes to provide treatment to two patients simultaneously, or treat two areas of the same patient simultaneously.

Therapeutic Taping

When an area of the body is injured, lymphatic fluid builds up and causes inflammation, swelling, discomfort, or pain. Decompressing the layers of fascia using therapeutic tape allows for greater movement of lymphatic fluid to facilitate the healing process. Correct taping provides support to muscles by improving the muscle’s ability to contract, even when it is weak, and helps it to not over-extend or over-contract. This taping is used for many common injuries, such as lower back pain, knee pain, shoulder pain, carpal tunnel syndrome, sprained ankles, and tennis elbow—just to name a few. Something as simple as 2 minutes to apply a specific therapeutic tape technique can help decrease swelling, muscle guarding, or increasing activation of a weak or injured muscle group. Sources for therapeutic tape include Kinesio Holding Corporation, Albuquerque, NM, which offers a wide range of roll and pre-cut tape, and Minneapolis-based company OPTP, which offers a variety of SpiderTech Tape in addition to Kinesio Tex Classic tape.

Virtual Reality

Virtual reality training (VRT) is a form of therapeutic exercise that utilizes virtual reality with handheld controllers that seamlessly respond to organic, human movements in virtual experiences. Every move, from turning and grabbing to pointing and lifting, is naturally connected from physical to virtual. Patients experience a visual stimulus while engaging muscle groups that are being rehabilitated. The virtual world also introduces novel visual input, which had not been associated with pain. It can allow a patient to perform therapeutic exercise with increased comfort and improved recruitment and movement patterns. VRT can be used for patients who suffer from various types of acute and chronic conditions to transition them to functional activities.

VRT has only a few contraindications and can help add fun to physical therapy rehabilitation, which is often overlooked. It can be combined with other types of physical therapy routines to magnify patient results. Two types of VRT are:

• Lcaros VRT—Allows patients in spinal and shoulder rehabilitation to facilitate various movements on a fixed axis. Patients only can move by shifting and controlling their core.
• Zoom VRT—A stationary bike that provides patients various visual simulations while encouraging them to move through a virtual reality world, while pedaling at various speeds.

Traditional Modalities Continue to Deliver

In some cases, pain symptoms can be addressed with the help of simple, low-tech tools that continue to be staples of the physical therapist’s tool kit. This group of technologies, such as topical analgesics and therapeutic hot and cold products, can especially provide affordable, easy-to-use treatment at home or in the clinic for the temporary relief of pain symptoms associated with joint and muscle pain.

Topical analgesics such as Sore No More from the Moab, Utah-headquartered company, Sore No More, act as temporary pain relievers that are applied directly to skin and are easy enough for patients to use at home as well as in the clinic. Sore No More is formulated with plant extracts that provide an anesthetic effect by depressing cutaneous sensory receptors. It is also made to absorb quickly and deeply.

Another topical analgesic in the PT marketplace is Flexall, from Tempe, Ariz-based Ari-Med Pharmaceuticals, which uses menthol and aloe vera gel to provide fast relief when applied directly to sprains or aches due to arthritis or muscle strain. Sombra, from Albuquerque, NM-headquartered Sombra, and China-Gel from Arlington Heights, Ill-headquartered China-Gel, are two other topical analgesic brands that offer products available to the PT market.

Wraps and wearable products that provide therapeutic hot and cold therapy are also an important part of the options physical therapists have for addressing temporary pain symptoms. Like topical analgesics, these types of products are user-friendly and can be applied at home as needed. Likewise, they provide a pain relief alternative that is non-addictive. One manufacturer in this space, Southwest Technologies, North Kansas City, Mo, offers Elasto-Gel hot and cold therapy products which can provide moist therapy heat or soothing cold. The company offers products designed to fit the hand, wrist, shoulder, and head, as well as a cervical collar and lumbar wraps. Elasto-Gel therapy wraps are available in more than 40 different shapes and sizes, and are made to be durable and reusable.

Battle Creek Equipment Co, Freemont, Ind, also provides an extensive selection of hot and cold therapy products for the PT market. The company’s Thermophore Moist Heat Packs are large enough to provide moist heat to the entre spinal area or across both shoulders. It can be effective for addressing back pain, arthritis, joint pain, and sciatica, among other conditions. Battle Creek Equipment also provides the Ice It! line of reusable cold wraps that easily fit the shoulder, knee, neck, ankle/elbow/foot, and other areas of the body. Ice it! products are made to be helpful in providing cold therapy that is quick to apply and safe to use.

Good Decision-Making: Still the Gold Standard

As DPTs evolve and grow their businesses, it’s not only important to incorporate new modalities. It’s critical to understand there is no universal recipe for which modalities benefit our patients to maximize their recovery. DPTs must utilize their own clinical decision-making abilities and connect to their patients’ needs. In turn, DPTs can determine the modalities prone to have the greatest positive effects on patients while aligning ourselves with the growing and future demands of the industry. PTP

Gary Struble, PT, DPT, OCS, is a founding member of the New Jersey Center of Physical Therapy. He has been recognized by the McKenzie Institute International as a Specialist in Mechanical Diagnosis and Treatment of Spine Injuries, and is further recognized by the American Physical Therapy Association as a Board Certified Orthopedic Clinical Specialist. Struble is a graduate of the Rutgers School of Health Related Professions and Kean University. For more information, contact PTPEditor@medqor.com.

 

Can Lasers Be Used In the Fight Against Opioids?

By Mark Callanen, PT, DPT, OCS

In response to the ongoing opioid crisis, the US Food and Drug Administration (FDA) announced in May that it is looking for alternative medical devices to treat pain. Class 4 therapy lasers, with their ability to reduce both acute and chronic pain1,2 in a noninvasive manner, may become part of the discussion.

Class 4 lasers in particular (those emitting more than 500 mW of light) are well suited for this purpose, due to their ability to impact sensory nerves in ways lower-powered, so-called “cold lasers” cannot. It has been shown that when higher irradiance (>250 mW/cm2) is applied directly to afferent axons, physical changes take place in the nerve that can create analgesic effects in minutes.3,4 This is easily attainable when treating superficial tissues. However, it is more challenging when treating deeper tissues, primarily due to the energy loss that takes place as light travels through tissue.5 Treating with more energy at the skin’s surface helps address this issue.5

While fast pain relief is associated with higher power lasers, most therapeutic lasers in fact have the ability to create longer-lasting relief via anti-inflammatory influences and positive chemical changes to damaged tissue that promote healing.6 Such findings have been reported repeatedly in literature over the past 25 years and demonstrate lasers’ ability to address chronic pain.

Laser is unique compared to most other modalities in that it has a direct impact on helping injured tissue work through not only the inflammatory, but the proliferative and remodeling stages of tissue repair via mitochondrial stimulation (photobiomodulation). Laser does not simply distract the CNS for a period of time like a TENS unit, or improve pain via heat-related mechanisms. While heat can be produced at the skin’s surface with higher power laser treatments, the photochemical changes that take place at deeper tissue levels represent the true mechanism of action that impacts the healing process.

References

1. Bjordal J, Couppé C, Chow RT, Tunér J, Ljunggren EA. A systematic review of low level laser therapy with location-specific doses for pain from chronic joint disorders. Aust J Physiother. 2003;49( 2):107-116.

2. Bjordal J, Johnson MI, Iversen V, Aimbire F, Lopes-Martins RA. Low-level laser therapy in acute pain: a systematic review of possible mechanisms of action and clinical effects in randomized placebo-controlled trials. Photomed Laser Surg. 2006;24(2):158-168.

3. Chow R, Armati P, Laakso EL, Bjordal JM, Baxter GD. Inhibitory effects of laser irradiation on peripheral mammalian nerves and relevance to analgesic effects: a systematic review. Photomed Laser Surg. 2011;29(6):365-381.

4. Holanda VM, Chavantes MC, Wu X, Anders JJ. The mechanistic basis for photobiomodulation therapy of neuropathic pain by near infrared laser light. Lasers Surg Med. 2017;49(5):516-524.

5. Morries LD, Cassano P, Henderson TA. Treatments for traumatic brain injury with emphasis on transcranial near-infrared laser phototherapy. Neuropsychiatr Dis Treat. 2015 Aug 20;11:2159-2175.

6. Huang YY, Chen AC, Carroll JD, Hamblin MR. Biphasic dose response in low level light therapy. Dose Response. 2009;7(4):358-383.