Physical Therapy in Chronic Pain
Physical therapists (PT) are as different in their areas of expertise as are physicians. However, physical therapists do not advertise their area of specialized knowledge. Some PT unfortunately assume the same principles apply whether treating acute pain, chronic pain, mobility problems, etc. Nothing could be further from the truth. For instance, some of the methods of treatment of acute injuries could actually be harmful to patients with chronic pain. It is necessary to understand the problems in chronic pain which need special consideration in the use of PT.
Because of abnormal posture and gait (walking) adopted by those in chronic pain, ligaments may be stretched beyond the point of their elasticity resulting in permanent derangement and dislocation of the bones they connect. Tendons can cause severe inflammation of bursa, muscles and tendons can entrap already inflammed nerves, and muscles can secondarily spasm due to a deeper pain generator which has its innervation from the same level as the muscle.
The goal of PT is to reduce inflammation and gradually change the posture and stance to the point these abnormal situations listed above are eradicated. In many cases, only PT is necessary and may preclude the need for injections or further therapy. However, just as often, a joint effort between PT and pain management is necessary in order to tolerate the expected and normal increases in pain that will early on accompany corrected posture, gait, muscle tone, etc.
It is extremely important to recognize passive modalities (ultrasound, massage, iontophoresis, etc.) that are often used successfully in acute injury PT do not work well in chronic pain, and may serve to further inflame tissues. Rehabilitation is dependent on the patient’s motivation to continue PT, even when it hurts. Without correction of underlying posture and gait, nothing pain management can do will result in long term success. Therefore, active patient participation in their rehabilitation is absolutely necessary. Allowing PTs to “do things” to you as the sole mode of therapy is counterproductive.
Engaging in home exercise programs, whether they be very active as in Jazzercise or aerobic exercise, or more stretch and fluid movement oriented such as Tai Chi are strongly recommended. Daily or more than once a day home sessions should be used optimally in addition to PT by a therapist. Listed on the next page are some of the therapies used by PT and their applicability in chronic pain.
Ionotophoresisis a technique of electrically stimulating the passage of chemicals through the skin. A charged electrode, containing the drug to be passed, is placed on the skin and a neutral electrode is used for current return. Steroids, local anesthetics, salt water, etc. are used in iontophoresis. Usually this is most useful in superficial problems such as tendons and joints. In chronic pain, bursitis and tendonitis may benefit more than deep tissue structures.
Phonophoresis is closely related to iontophoresis, except ultrasonic waves of energy are used to transfer the medications into the skin. The penetration may be a bit deeper with this unit. At a power of 1.5 W/cm2 at 3.3MHz, hydrocortisone is delivered 1.7cm below the skin surface according to a study by Dan Black at the Idaho State Univ. Dept. Physical Therapy.
Traction therapy involves the use of gentle sustained or intermittent traction to alleviate pressure on discs and intervertebral structures. Use of traction in herniated discs is one of the mainstays of conservative treatments. Automated computerized machines such as VAX-D and the DRS use short pulses of traction with interspersed rest periods to prevent muscle spasms and tearing.
Massage is integrally a part of PT, but is also an alternative health therapy. PT massage focuses on specific muscle groups, breaking up scar tissue and adhesions, and in reduction of muscle spasm in order to effect a better posture and gait. Alternative therapy massage on the other hand, focuses on superficial skin structures or on deep abdominal structures such as with Rolfing. The latter should be avoided at all costs since the therapeutic value is negated by the risk of liver or spleen rupture.
Physical therapy also includes electrostimulation, mobilization, stretching, muscle group functional retraining, pool therapy, hydrotherapy, and various balanced and controlled exercises. PT is one of the lynchpins of rehabilitation of patients suffering from chronic pain.