Pain management program is a multi-disciplinary approach that aims at providing pain relief and restoration of normal function by either drugs and/or interventions. Pain management program may be desirable in selected patients of back pain or sciatica, neck pain, failed back syndrome, reflex sympathetic dystrophy, myofascial pain, fibromyalgia, facial pain, neuropathic pain, headaches, cancer pain, shingles, chronic pelvic pain, spinal pain syndromes, and phantom limb pain.
The interventions include electrotherapy, manipulative therapy, hydrotherapy, nerve blocks or radiofrequency ablation, biofeedback, relaxation and stress management.
Pain management program aims to increase and reduce the level of functioning and quality life while reducing your sense of suffering.
Pain management programs are designed to help a person with pain become part of the treatment team and take an active role in regaining control of his or her life in spite of the pain.
Pain management program involves a team of healthcare providers working directly with the person with pain with a variety of measurement, interventions, and strategies. The treatment is never focused on just the pain, but the person as well.
The team consists patient with pain and his support system [ family, friends, neighbors], physicians, physician assistants, nurses, psychologists, physical, occupational and recreational therapists, vocational counselors, pharmacists, dieticians, social workers, and other support staff.
Team members may vary from one program to the next. The program is patient and family-centered and includes formal follow-up is scheduled
Hydrotherapy in Pain Management
In hydrotherapy, water is used as a therapeutic measure. It includes ice water therapy and pool hydrotherapy.
The pool therapy is one wherein patients are mobilized to do activities in a warm swimming pool.
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
- Degenerative arthritis
- Neurological disorders-hemiplegia, paraplegia
It is contraindicated in
- Haemodynamically unstable patients
- Major systemic illness
- Vertigo, epilepsy
Cold therapy is used in the form of ice packs, vapocoolant sprays and ice massage.
It is most useful in acute musculoskeletal pain associated with sports injuries or trauma.
Whenever cold stimulus (ice pack) is applied to the skin, it melts and removes heat from tissues. This leads to vasoconstriction (The blood vessels get constricted, their lumen and their capacity to carry blood increases), reduction of nerve conductivity (As a result the nerve becomes less sensitive), reduction of muscle spasm and spasticity. Once the cold stimulus is taken off, the temperature of the area reaches a normal level by vasodilatation.
This vasodilatation brings fresh blood which flushes inflammatory medications. Again reapplication of cold stimulus repeats the same event.
Alternate vasoconstriction and vasodilatation help in tissues healing and pain relief.
Ice can be applied in towels as a pack or by immersion in a bath. Damp towels dipped in an ice and water mixture or containing crushed or flaked ice, can be wrapped round painful and swollen joints. The towels are changed every few minutes.
In ice massage, an ice cube is wrapped in a towel at one end and the free end is massaged over the skin. This can act as counterirritant if applied for 5 to 7 minute to relieve pain and muscle spasm.
Ice therapy can alleviate pain frequently and the onset of pain can be delayed by early application of therapy. This will reduce bleeding and edema by causing vasoconstriction.
One should be careful while applying ice therapy for extremities like digits and toes for the risk of ischemia or decreased supply of the oxygen to the tissues
Ultrasound therapy involves the production of longitudinal mechanical waves above the audible range (20 KHz). The frequencies used in physiotherapy vary from 0.75 MHz to 3 MHz. These are produced by distortion of quartz crystal, by a high-frequency alternating current.
These sound waves require a conducting medium like oil or water to reach from the probe head to tissues. The probe head should be applied perpendicular to tissues to present refraction and it should be moved continuously to prevent concentration on one tissue area. Higher the frequency, greater the absorption and smaller the depth of penetration.
Heat Therapy in Pain Management
Heat therapy is also called as thermotherapy. Local application of heat can provide pain relief and reduce muscle spasm. Most chronic pain patients are aware of superficial heat applied locally in the form of a hot water bottle, or generally in the form of a hot bath or shower.
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
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.
Heat therapy is indicated in painful conditions like trauma, degenerative joint disease, and chronic inflammatory arthritis.
It is contraindicated in open wounds and skin infections
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 the 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 a drawback of providing heat on one aspect only and the patient has to remain in one position for treatment
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 molded to the contour of the body. Layers of towels must be placed around 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 heavy and discomforting.
Deep Heat 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., shortwave diathermy, microwave diathermy.
Shortwave diathermy is an application to tissues of an 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 the arrangement of the field of the electrical impedance of tissues. The diathermy may be applied in a continuous fashion or pulse waveform.
The therapeutic effect of a continuous mode is the same as the pulsed mode.
Shortwave diathermy produces a greater and more rapid rise in temperature than the conductive methods of heat to a depth of 3 to 5 cm.
It can be applied to both superficial and deep lesions and large areas can be attended.
It is indicated in soft tissue injuries, inflammatory arthritis, and degenerative arthritis
Microwave Diathermy 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 (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.
Interferential therapy uses 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.
It is indicated in chronic degenerative arthritis, backache, complex regional pain syndrome and soft tissue injuries
Low-frequency currents (1 Hz to 1000 Hz)
The low frequency requires 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.
Low-frequency currents stimulate both motor and sensory component of nerve.
Most often these currents are used for reduction of muscle contraction which must be normally innervated to respond to these currents.
These currents otherwise do not find much use in clinical practice, because of their sensory stimulation.
Manipulative Therapy in Pain Management
Manipulative therapy includes massage therapy, mobilization of the joints and stretching of the tissues for providing pain relief by muscle relaxation and improvement in local blood flow.
Indications of manipulative therapy are muscle spasm or tightness, pain, adherent scar tissue, and post-traumatic edema
It is contraindicated in acute inflammation, Infective skin lesions, eczema or recent fractures.
The term massage has been replaced by soft tissue technique and this manipulative 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 the benefit is produced by local reflex activity or by mechanical stimulation.
Passive Mobilization of Joints
Mobility of joints might get restricted because of degenerative changes, trauma, chronic pain. The restricting factors may be pain, muscle spasm, edema, fibrous contracture of fascia, ligament or capsule.
Restoration of normal function of joints is very important and passive mobilization helps to restore joint function.
Pain itself may be relieved by restoring normal movements. The relief could be because of the 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 have 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 the removal of metabolites which act as an irritant to the nociceptive nerve endings in the tissues and pain are 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 are
- Inflammatory arthritis with an acute flare-up
- Instability of joints
- Spinal cord compression
- Vertebrobasilar insufficiency
- Severe pain which is easily provoked
- Local malignancy
Passive stretching of soft tissues
In this, soft issues are passively stretch. 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 an 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 a sprint, sportspersons perform auto stretching of muscles, ligaments, and fascia. The 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 holds again.
This is repeated 3-4 times.
The procedure is then applied to the opposite side. This manipulative therapy technique should be performed daily.