Massage has been used for centuries as a form of stimulation technique aimed at muscle relaxation and improvement in local blood flow. This indirectly gives pain relief. Massage is a part of manipulation therapy which consists of

• Soft tissue technique (massage)
• Passive mobilization of joints
• Passive stretching of soft tissues
• Autostretching of soft tissues

The term ‘massage’ has been replaced by “soft tissue technique” terminology in view of bad publicity given to massage in late 70s. This therapy involves stroking, kneading picking up, skin rolling etc., of soft tissues (muscles with their fascial sheaths, ligaments, tendons and skin).

It is not known whether benefit is produced by local reflex activity or by mechanical stimulation.

Indications

• Muscle spasm or tightness
• Pain
• Scar tissue-adherent and limiting movement
• Post-traumatic oedema

Contraindications

• Acute inflammation
• Infective skin lesions-eczema
• Recent fractures

Related posts:

1. Passive And Auto Stretching of Soft Tissue of Manipulative Therapy in Pain Management
2. Passive Mobilization Of Joints – Manipulative Therapy In Pain Management
3. Role Of Cold Therapy in Pain Management

This is a stretching force applied in a longitudinal direction of the spine.  Traction is supposed to separate vertebral bodies, stretches fibrous tissue, improve movements of facet joints,  better drainage of fluid around the nerve roots, and improves circulation.

Traction is of two types – sustained and oscillatory. While sustained hold is used for injuries, root compression and muscle spasm, oscillatory  is used for degenerative changes.

Position

In  cases where the traction is used to treat the root pain or spasm of the muscles, the spine position is adjusted to enable the force to be effective at the target segment.

For example flexing the spine incase of lower cervical regions or flattening the spine by flexinge knees and hips and tilting the pelvis backwards in cases of lower lumbar traction.

Force

Smallest force providing pain relief should be utilized. For nerve root pain, the aim should be 50 % reduction. If more weight is used, the pain can be drastically increased when the traction is removed.

For stiffness and degenerative changes, effective force varies from 3 kg to 7 kg.

Time

For nerve root pain, sustained traction may be left on for 20-30 minutes, released for 5-10 minutes and then re-applied for a further 20-30 minutes. Treatment is generally based on a daily basis until the overall pain reduction is 75 percent.

For degenerative changes or regional stiffness, 10-20 minutes, repeated three times a week until improvement stops.

Sustained or oscillatory Traction

Oscillatory traction is useful for degenerative joint stiffness.

Follow Up

Improvement is noted by reduction in pain intensity, longer pain free spells or increased mobility.

Immediately after sustained traction is removed, spinal mobility is often reduced. This effect wears off in 1-2 hrs. Testing movements therefore should be delayed until the next treatment.

If after four treatments with tractions there is no improvement, other modalities should be considered. A combination of passive oscillatory movements (given first) and traction is often more effective for general stiffness.

Postural training and exercises are essential components of pain management.

Related posts:

1. A Short Guide To Physical Exercises For Spine
2. Exercise For Back Pain Relief-Extension Exercises

TENS Unit - Credit Wikipedia

Transcutaneous electrical nerve stimulation (TENS) is in essence application of electric current for control of pain. It involves a principle wherein the sensory myelinated fibres are stimulated without discomfort to the patient and without muscle contraction. TENS is a non-invasive, very safe method to reduce pain, both acute and chronic. While ther eare conflicting views on its efficacy, its effectiveness for postoperative pain, osteoarthritis, and chronic musculoskeletal pain has been confirmed by systemic reviews.

How Does TENS Act?

The  stimulation activates local inhibitory circuits within the dorsal horn of spinal cord. These inhibitory circuits reduce the transmission of painful impulse through the spinal cord.

This stimulation is done by a frequency of 70 Hz, patients feel comfortable at this level of stimulation. TENS equipment has a frequency of 1 to 100 Hz. When stimulated at high frequency of 70 Hz, the pain relief is shorter and of fast onset.

But stimulation at low frequency has a slow onset of pain relief and  long after effect. Some equipments have combination of both, high frequency bursts repeated at low frequency. Clinically rectangular waveform width between 0.1 to 0.5 msec is utilized. The current is delivered through electrodes with gel application.

Contraindications

• Patients with pacemakers

Guidelines

• For chronic pain, 3 hrs sitting per day for 4 to 6 weeks.

Side effects

• Allergic response to gel/electrode with local erythema.
• Painful stimulation with inadequate gel application.

TENS does a good job initially, providing good relief upto 70 percent to start with. As time passes, the pain relief remains at about 20 percent to 30 percent. But its noninvasive nature, portability and domestic use are quite attractive.

TENS is ineffective in psychogenic pain and pain of multiple sites.

Safety

TENS electrodes should not be placed

• On or near the eyes
• In the mouth
• Transcerebrally i.e. On either side of temple
• On the front of the neck due to the risk of vasovagal reflex leading to hypotension
• On areas of numb skin/decreased sensation
• On broken skin areas or wounds
• On or near the trigeminal nerve if you have a history of herpes zoster induced trigeminal neuralgia.

Related posts:

1. Soft Tissue Technique Or Massage In Pain Management
2. Heat Therapy in Pain Management
3. Role Of Cold Therapy in Pain Management

In soft tissues after any injury immediate repair takes place by formation of fibrous tissue (scar). This scar has an inherent property of contracture and tends to bind tissues together. When this scar tissue forms in fascia, muscles and ligaments it limits the function of tissue because of its lower elasticity.

It hurts when the scar tissue is stretched beyond a limit. Early ambulation is essential after injury to ensure that scar tissue is laid down in the correct plane of movement. Despite all these precautions, nerve entrapment happens in scar tissue.

Passive stretching of soft tissues is most often done for frozen shoulder, early osteoarthritis, sprain and other conditions.

Passive stretching is designed to lengthen shortened scar tissue, complement massage and joint mobilization.

Active stretching of soft tissues

This is widely practiced in sports. Before starting of sprint, sports persons perform auto stretching of muscles, ligaments and fascia. Exact benefit is not known. It is supposed to warm up tissues before major activity.

This is supposed to provide flexibility and therefore a greater range of movement. The person takes up the position with the appropriate structure or tissues (hamstrings) on the stretch, feels the tightness and holds for 30-60 seconds; then as the tightness reduced he takes up the slack and hold again.

This is repeated 3-4 times. Te procedure is then applied to the opposite side. The technique should be performed daily.

Related posts:

1. Soft Tissue Technique Or Massage In Pain Management
2. Passive Mobilization Of Joints – Manipulative Therapy In Pain Management
3. Role Of Cold Therapy in Pain Management

The pelvic tilt is a posture that  reduces stress on the lower back caused due to sitting or standing.

Lie on your back with your knees bent and your head comfortably supported.

You would notice a space between your lower back and the surface on which you are lying. (You can find this by inserting yourfingers underneath your back.)

Squeeze your buttocks together, tighten your abdominal muscles, and raise your buttocks slightly off the floor until the small of back is pressing flat against the surface. This is the pelvic tilt position.

Hold this position for 10 seconds. Then relax completely.

The pelvic tilt rotates your pelvic bone and decreases the curve in the lower part of your spine.

Lateral Trunk Stretch

This exercise stretches the muscle on both sides of the abdomen.

Bend your knees and put your hands behind your head with your elbows outstretched. Then cross your left leg over your right (hold for 15 seconds).

Use the left leg to push the right knee towards the floor until you feel a good stretch. Push your knee as close to the floor as you can. Hold the stretch for 15 seconds. Then carry out this exercise using right leg over the left knee.

Prone Lift

This exercise strengthens back muscles. Turn over on your stomach and place a firm cushion under your pelvis and lower abdomen. Tighten your buttocks.

Slowly lift your head and chest off the floor. Hold this position for 5 seconds. Then let yourself down slowly and relax completely. Initially  keep your arms at your sides. As you practice you can make this tougher by extending the arma straight in front.  Put your hands behind your head for even making it more difficult.

Seated Lumbar Flexion

This exercise stretches the lower back.

In sitting position, put your soles together and let your knees fall apart wide enough. With outstretched arms, slowly bend forward from the hips as far as you can without pain. Imagine you’re reaching for a handle just beyond the tips of your fingers. You would feel a stretch in your back.

Hold this position 15 seconds.

Then return to the up-right position and relax completely.

Related posts:

1. Exercise For Back Pain Relief-Extension Exercises
2. Physical Exercise For Back Pain Relief-Hamstring Stretch Exercise
3. Physical Exercises For Neck Pain Relief

Restoration of normal function of joints is very important.

Pain itself may be relieved by restoring normal movements. The relief could be because of direct effect of passive joints movements by the stimulation of mechanoreceptors, which in turn inhibits the transmission of pain impulses from the periphery through the spinal cord to the brain.

Rhythmical passive movements of joints has effects on skin, fascia, muscles, tendons and ligaments. This probably moves fluid through the tissue planes and increase lymphatic and venous drainage. This results in removal of metabolites which act as irritant to the nonciceptive nerve endings in the tissues and pain is reduced.

Treatment of under limiting factors and regaining movement and maintaining it by exercise is often effective in pain relief or reduction.

Contraindications for passive mobilization

• Inflammatory arthritis with acute flare up
• Instability of joints
• Spinal cord compression
• Vertebrobasilar insufficiency
• Severe pain which is easily provoked
• Local malignancy
• Infection

Related posts:

1. Passive And Auto Stretching of Soft Tissue of Manipulative Therapy in Pain Management
2. Role Of Cold Therapy in Pain Management
3. Heat Therapy in Pain Management

This warmth of water reduces pain and relaxes muscle spasm. Water with its buoyancy counteracts gravity, provides support and relieves weight bearing in degenerated joints or unstable joints.

Pool therapy is indicated in

Indications

• Degenerative arthritis
• Neurological disorders-hemiplegia, paraplegia

Contraindications

• Infection
• Haemodynamically unstable patients
• Major systemic illness
• Tracheostomy
• Vertigo, epilepsy
• Others

Related posts:

1. Heat Therapy in Pain Management
2. Ultrasound Therapy In Pain Management
3. Passive Mobilization Of Joints – Manipulative Therapy In Pain Management

Straighten your left leg in front of you with the back of your knee firmly on the floor and your toes pointed straight up. Bend your right leg so that the sole of the foot is touching the inside of the left knee.

Hold for 15 seconds.

Slowly bend forward from the hips, reaching with both hands toward your left foot until you feel a good stretch in the back of your thigh. Bend as far as you can without pain.

Hold this position for 15 seconds

Slowly return to the upright position and relax. Then switch and stretch the other thigh.

Put your right leg straight ahead with your knee flat on the floor and toes pointed up. Bend the left leg so that the sole of that foot is against the right knee. Hold for 15 seconds.

Then bend forward from the hips as far as you can without pain. Hold that stretch for 15 seconds. Then return to the resting position.

Repeat once more time on each side.

Related posts:

1. Exercise For Back Pain Relief-Extension Exercises
2. Conditioning Exercises For Back Pain Relief
3. Physical Exercises For Neck Pain Relief

There are different ways by which heat therapy can be provided. They are broadly classified as:

Superficial heat therapy

• Paraffin wax
• Infrared radiation
• Heat pad
• Hot moist packs

Deep heat therapy

• High frequency currents
• Medium frequency currents
• Low frequency currents

The superficial heat can reach up to 1 to 2 cm depth, while deep heat has the reach beyond this.

This superficial heat produces different response including changes in neuromuscular activity, blood flow, capillary permeability, enzymatic activity and pain.

The deep heat  delivers energy directly to deeper tissue, which improves muscular function, blood flow and local reflexes by suppressing sympathetic over-activity.

Superficial Heat Therapy

Paraffin Wax

This wax has a low melting point and is contained in a bath controlled between 40 degree Celsius and 44 degree Celsius. The wax heats more slowly but retains its heat for a longer period than water. As the wax solidifies on the skin, the energy released by the latent heat of fusion results in heating of the tissues.

It completely surrounds the part being treated and there is very little danger of burns. It is difficult to apply extremities and hence its main use will be for hands and feet.

Indications

Painful conditions like

• Pain after trauma
• Degenerative joint disease
• Chronic inflammatory arthritis

Contraindications

• Open wounds
• Skin infections

Infrared Radiation

the electromagnetic rays beyond 770 mm to 1000 mm are termed as infrared radiation. The infrared radiations can reach only up to superficial epidermis. When these radiations hit the body, the radiant heat is converted into heat.

Any part of body can be treated, but the patient must be positioned so that the rays strike the part at 90 degree Celsius for maximum absorption. However it has drawback of providing heat on one aspect only and patient has to remain in one position for treatment.

• Tissues are heated directly on one aspect only.
• Patient should remain in one position throughout the treatment.

Indication

• Large superficial areas can be treated.
• Promoting healing in uninfected wound
• Relieving pain and muscle spasm following trauma.
• Chronic arthritis.

Heat Pads

Heat pads supply dry heat.  A heating pad has three levels of heat, and heat passes to tissues by conduction. However, dry heat is conducted less uniformly than moist heat. It is very useful in neck and back pain.

Hot Moist Packs

These are canvas bags filled with a hydrophilic substance and stored in a thermostatically controlled cabinet of water between 75 degree Celsius to 80 degree Celsius. The packs vary in size and shape and are returned to the cabinet for reheating after use.

The area to be treated should be totally covered by the pack, which is moulded to the contour of the body. Layers of towels must be placed round the pack to separate it from the patient’s skin. The superficial tissues are heated by conduction, relieving pain and muscle spasm.

Heat in this is conducted more uniformly than dry heat. These packs are useful on uneven surfaces because they can be easily molded to the surface. But they are heavey and discomforting.

Deep Therapy

The electromagnetic fields are applied in electrotherapy to tissues at different frequencies for therapeutic effect. All these frequencies are used for different benefits.

These electric fields are classified in the following way on the basis of frequencies generated.

High frequency (10,000 Hz and above)

High frequency currents cannot stimulate skin or muscle because of their high frequencies. They can produce only thermal effects, e.g., short wave diathermy, microwave diathermy.

Medium frequency currents (1000 Hz to 10,000)

These currents reduce the skin resistance (frequency and skin resistance are inversely proportional) and hence require low current intensity to achieve the desired effects. Because of low intensity it results in less sensory discomfort, e.g., interferential therapy.

Low frequency currents (1 Hz to 1000 Hz)

The low frequency require high intensity current to overcome the skin resistance. This high current leads to marked sensory stimulation to the patient, e.g., faradic and direct current.

High Frequency Currents

Short wave diathermy

Short wave diathermy is an application to tissues of electrical field which oscillates at a frequency of 27.12 MHz and a wavelength of 11.06 M. This field generates heat within the tissues by movement of molecules and ions.

The heat distribution depends on arrangement of field of electrical impedance of tissues. The diathermy may be applied in a continuous fashion or pulse wave form.

The therapeutic effect of continuous mode is same as pulsed mode.

Short wave diathermy produces a greater and more rapid raise in temperature than the conductive methods of heat to a depth of 3 to 5 cm.

Advantages

• Both superficial and deep lesions can be attended
• Large areas can be treated
• Useful for soft tissue injuries

Indications

• Soft tissue injuries
• Inflammatory arthritis
• Degenerative arthritis

Microwave diathermy

This is an application of electromagnetic radiations with a wavelength of 12.25 cm and frequency of 2450 MHz. When these microwaves are absorbed in the tissues, heat is produced. The depth of penetration is up to 3 cm which is more superficial than shortwave diathermy. These waves are absorbed by fluid tissues such as muscles and less by fat and bone. This therapy is good for superficial tissues.

Medium Frequency Currents

Interferential therapy

In this therapy two medium frequency currents at constant intensity but different frequencies are applied to the body at the same time, the intensity of the combined current will increase and decrease rhythmically.

Indications

• Chronic degeneration arthritis
• Backache
• Complex regional pain syndrome
• Soft tissue injuries

Low Frequency Currents

Low frequency currents stimulate both motor and sensory component of nerve. If these currents are not modified, they an produce titanic contractions.

Most often these currents are used for reduction of muscle contraction which must be normally innervated to respond to these currents.

These currents other wise do not find much use in clinical practice, because of their sensory stimulation.

Related posts:

1. Ultrasound Therapy In Pain Management
2. Role Of Cold Therapy in Pain Management
3. Passive Mobilization Of Joints – Manipulative Therapy In Pain Management

Flexion of the spine brings you torso towards your foot on the anterior aspect. When you bend yourself to touch your feet, it is the flexion that is responsible.

Extension is opposite to the flexion. If you lie on your stomach and lift your head and shoulders off the ground, this would cause extension of the spine.

These exercises may help some people with back pain. However, certain medical conditions that cause back pain can be aggravated by these exercises, so they must be done with caution and under supervision, at least for an initial period.

When doing those exercises, if  the pain becomes severe or it  radiates toward other portions, exercise should be discontinued.

Exercise 1

Lie face down. Rest your arms alongside your body with your head turned to one side. Relax yourself and release all of the tension from the muscles in your lower back. Hold this position for at least 10 seconds mimimum. Do this exercise up to six times a day.

Exercise 2

Lie face down in the resting position. Take a few deep breaths to help you relax completely and release the tension in the muscles of your lower back. Slide your forearms forward until your elbows are under your shoulders. Then slowly raise your upper body as far as you can go without. Hold that position for 10-15 seonds as you perform the deep breathing relaxation technique.

Then slowly lower your body to the ground and allow yourself to relax completely.

Exercise 3

This is similar to esercise 2. While lying face down, slowly straighten your arms to raise the upper half of your body as far as you can without pain. Relax your buttocks, pelvis, hips, and legs completely and then let your back sag.  Each time you do the exercise, try to push yourself up a little higher within limits of your pain.

Do this for 2-5 minutes.

Exercise 4

Stand up with your feet approximately shoulder width apart. Put your hands on the small of your back, with your fingers pointing toward the center of your back and your thumbs pointing forward. Keeping your knees straight, very slowly bend your body backward from the waist against your hands. Bend as far as you can without greatly increasing the pain and hold that position for about 10-15 seconds.

These exercises can be done ten times per session, for up to six sessions per day.

Each time you do the exercise, try to go a little further.

Exercises such as swimming, bicycling and walking can strengthen abdominal, shoulder and back muscles. and can be initiated along with.

People neckpain/backpain should avoid certain activities that place undue stress on the spine or require sudden movements such as weightlifting.

Related posts:

1. Physical Exercise For Back Pain Relief-Hamstring Stretch Exercise
2. Conditioning Exercises For Back Pain Relief
3. Physical Exercises For Neck Pain Relief