The ASAM Principles of Addiction Medicine 5th Edition

95. Rehabilitation Approaches to Pain Management

Steven Stanos, DO and Randy L. Calisoff, MD

CHAPTER OUTLINE

■  ACTIVE PHYSICAL THERAPY (PT)

■  OCCUPATIONAL THERAPY (OT)

■  PSYCHOLOGICAL INTERVENTIONS AS PART OF A PAIN REHABILITATION PLAN

■  MODALITIES USED IN ACUTE AND CHRONIC PAIN CONDITIONS

■  CONCLUSION

Rehabilitation may be described as a “return to ability … the return to the fullest physical, mental, social, vocational, and economic usefulness that is possible for the individual.” The focus is placed more on one’s abilities rather than his or her disabilities (1). The patient with substance abuse or addictive disorder may also be faced with an additional challenge of comorbid chronic pain. A recent systematic review found that nonmedical users of prescription opioids had two to three times greater mental health problems and pain than did the general population (2). Incorporating a rehabilitation-based approach to treating chronic pain can serve as a valuable tool for managing chronic pain patients with and without addictive disease (3,4).

A number of chronic and acute pain conditions can benefit from a wide range of nonpharmacologic interventions. A rehabilitation-based approach focuses on a staged approach to addressing the range of acute to chronic pain conditions. A focused history and physical exam can help to identify areas of impairment and guide subsequent treatment interventions and the development of a comprehensive rehabilitation plan. More chronic presentations may need psychological and vocational interventions as well. In carefully selected patients, some interventional procedures (i.e., epidural injections for acute radicular pain or trigger point injections for myofascial pain complaints) may provide additional tools for the pain clinician but will not be the focus of this chapter. The chapter overviews active and passive therapies for acute and chronic pain conditions, including modalities, active physical and occupational therapy, and team approaches to comprehensive care.

The World Health Organization (WHO) has embraced the concept of a “biopsychosocial model” for assessing and treating chronic pain patients, including those with substance abuse or other psychiatric disorders (5). A rehabilitation approach for assessing and treating pain is based on a conceptualization of the experience of pain as only one part of the dynamic interplay between physical changes in the nervous system and psychological factors. Nociceptive pathways can be affected by tissue-related changes as well as psychosocial factors including stress, anxiety, depression, external factors such as the environment, and past experiences. The resulting pain experienced by the patient will be manifested by overt pain behaviors and suffering (6). From a rehabilitation perspective, all of these biopsychosocial factors should be considered when developing and delivering a pain management treatment program.

In assessing complaints, one should focus on the patient’s individual “impairments” (i.e., physical or psychological abnormality), his or her effect on function or “disability” (i.e., a restriction or lack of ability to perform a function), and how that affects his or her place in society or creates a “handicap” (7). The WHO has broadened the concept of “chronic pain” to include the unique relationship among an individual patient’s pain and related activities, function, and participation in society, including the influence of related environmental and personal factors (8) (see Fig. 95-1).

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FIGURE 95-1 The WHO model of factors interacting with chronic pain and activity.

A conceptual model based on disease management approaches similar to those for diabetes, heart disease, and asthma can be applied to the treatment of many chronic pain conditions (9) (see Fig. 95-2). In this model, moving from left (parallel practice) to right (integrative) includes moving from a biomedical, disease-focused approach to a collaborative integrative team-based treatment model. Moving across the continuum, the philosophy emphasizes the whole person, with little reliance on hierarchy and flexible roles among clinicians. Acute pain conditions typically respond to a biomedical approach focused on acute management, decreasing local soft tissue swelling, and immobilization. Similarly, parallel practice, for example, could involve an emergency team working efficiently on a patient presenting with cardiac pain. Individual roles are specifically defined, and extensive communication is not necessary. Collaborative models may involve a physician referring a patient to a different specialist for consultation. Coordinated models may include the additional use of a case manager to help coordinate delivery and communication of care. A “multidisciplinary” approach includes the use of one or a number of allied health disciplines, such as physical therapy (PT) or occupational therapy (OT) directed by a senior provider. In a multidisciplinary care, clinicians need not be in the same facility, and communication may vary, as may the transfer of records and reports. As the presenting complaint becomes more chronic, a more collaborative approach involving the coordination of multiple caregivers defines an “interdisciplinary approach” (10).

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FIGURE 95-2 Models of medical care. From Boon H, et al. From parallel practice to integrative health care: a conceptual framework. BMC Health Serv Res 2004;4:15.

In an interdisciplinary model, care is usually provided at one facility, where patients participate in a number of therapies, working with multiple disciplines and health care providers. Treatments may include physical and occupational therapy, psychotherapy (e.g., cognitive–behavioral therapy) and relaxation training, aerobic conditioning, education, vocational rehabilitation, and medical management. These programs can vary from 1 to 2 days per week to more comprehensive, 6 to 8 hours per day, 4 to 5 day per week, 15- to 20-day programs. Such programs are usually provided in an outpatient setting (11).

Treatments focus on helping the patient to acquire pain management skills, decrease pain, improve psychosocial functioning, and return to leisure and vocational function. We will describe allied health disciplines that can be used in a unimodal manner or as part of a comprehensive rehabilitation-based treatment plan.

ACTIVE PHYSICAL THERAPY (PT)

Physical therapy includes, among other functions, the application of modalities, physical agents (see modalities below), therapeutic exercise, functional training in home and work activities, and manual therapy (http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/BOD/Practice/ScopeofPractice.pdf Amer Phys Therapy Association).

Physical therapy treatment primarily includes 1-hour sessions, which can include patient education, instruction in exercises and stretches, core strengthening, gait training, manual therapy, and pool or aquatic therapy, with progression of activities over several therapy visits. Patients are given short- and long-term therapy goals and instruction in exercises and stretches. The PT may also dispense equipment, braces, and supports.

The addiction clinician can refer patients for evaluation and treatment to a physical therapist. Follow-up should include monitoring for compliance. Many times, reviewing a patient’s exercise program and stretches will help to reinforce with the patient the importance of the patient’s active role in the rehabilitation process.

The goal of any referral to a physical therapist is to establish a patient in an independent therapeutic exercise program. The basic principles of a therapeutic exercise prescription include the following:

1.  Functional evaluation and assessment of dysfunction and impairments

2.  Evaluation and management of motor control (i.e., strength and balance)

3.  Identification and management of bony and joint kinematic limitations (i.e., joint contracture, soft tissue restrictions)

4.  Assessments of movement patterns followed by strategies for improvement or facilitation of synergistic movement patterns (12)

Physical Therapy Approaches to Stretching

The physical therapist can assess joint range of motion, soft tissue changes, and strength deficits as they relate to a functional unit, such as the shoulder, knee, and cervical or lumbar spine. Joint hypomobility is a frequent cause of pain and many times can be the result of poor posture, weak and inhibited muscles, and tight soft tissue. Muscle surrounding the affected area may also develop compensatory activation patterns and neural dysfunction. Various stretching techniques can be used and guided by the therapist and over time performed individually by the patient. Basic types of stretching include ballistic, passive, static, and neuromuscular facilitation. Ballistic stretching uses repetitive rapid application of force in a jerking or bouncing manner in which momentum helps to carry the body part through a range of motion until muscles are stretched to their physiologic maximums. More commonly used stretching for chronic pain includes static stretching and proprioceptive neuromuscular facilitation (PNF).

Static stretching techniques involve stretching an antagonist muscle passively by putting the segment in a maximal position of stretch and holding for 10 to 60 seconds. This stretching is repeated four to six times and often incorporates the patient’s own body weight, the assistance of a therapist, or stretching equipment (13). PNF techniques can be also useful for improving flexibility. Different types of PNF exercises include contract–relax, useful when range of motion is limited by muscle or soft tissue tightness, and hold–relax, which includes additional light pressure from the therapist, producing maximal stretch of the involved antagonist muscle groups. Myofascial release is a physical or occupational therapy technique that requires specific training and can accomplish stretching of deeper fascia and connective tissue. In some states, therapists may also be licensed in such interventional approaches for myofascial pain as dry needle insertion and trigger point injections (14,15).

A growing area of therapy includes stretching the peri-neural tissues or “neurodynamic therapy,” commonly used in cervical and lumbar radicular pain or peripheral nerve compression disorders (e.g., ulnar neuropathy of the elbow, median neuropathy at the wrist) (16). Here, neural tissue may become constrained in tight muscle or soft tissue causing increased nerve excitability and such symptoms as paresthesias and dysesthesias in the distribution of specific nerves. Butler and others have eloquently described stretching techniques that can be taught to a patient as part of a therapy program (17).

Aquatic Therapy

Numerous studies have found aquatic therapy to be beneficial in a variety of acute and chronic pain conditions, including fibromyalgia, spinal cord injury, osteoarthritis, and various orthopedic injuries (18). Therapy is usually supervised by a physical therapist, occupational therapist, or trainer. Treatment is usually in a group setting with the goal of instructing patients in the performance of exercises that can be performed in the water and continued independently. The beneficial effects of aquatic therapy include decreases in joint compression forces, the counteraction of gravitational obstacles by buoyancy, decreased pain, and reduced protective muscle spasm (19).

The physical properties of water that are useful include “weightlessness” and resistive forces against which patients can apply force.

Common indications for therapy include peripheral edema, decreased range of motion and strength, impaired balance, weight-bearing restrictions due to injury or surgery, gait abnormalities, and cardiovascular deconditioning (20,21). In chronic neck and low back pain, aquatic therapy may be provided initially, until improved conditioning permits successful application of land-based therapy. Aquatic therapy may help to eliminate fear-related avoidance of movement, to improve range of motion, and to initiate stretching and strengthening.

A significant percentage of chronic pain conditions involves disorders of the neck and lumbar spine, which accounts for a large proportion of those in need of treatment. Besides passive modalities used for acute pain management (see below), physical therapy–directed exercises may help patients improve function and decrease pain. Acute and chronic low back pain patients may benefit from referral to a physical therapist for instruction in one of a number of programs, such as lumbar stabilization or core strengthening, or for specialized directional preference treatments such as McKenzie-based therapy.

Lumbar and Cervical Stabilization

Stabilization exercises focus on strengthening weak and inhibited muscles and strengthening or “stabilizing” muscles that surround the spine, thereby improving muscular support (22). Assessing and improving the “core” is the cornerstone of any stabilization program for the lumbar spine, and similar principles can be applied to cervical and joint-related pain conditions (23). The core is defined as the lumbopelvic– hip complex, thought to include over 29 muscles attaching in this region of the body. Key lumbopelvic–hip muscles include those attaching to the lumbar spine (transversospinalis group, erector spinae, quadratus lumborum, and latissimus dorsi), abdominal muscles (rectus abdominus, external and internal obliques, and transversus abdominus), and key hip muscles (gluteus maximus, gluteus medius, and psoas) (24). Cervical stabilization focuses on improving spine mechanics (i.e., cervical flexion, extension, side bending, and rotation), improving maladaptive postures, increasing cervical extensor and posterior scapular muscle strength, and usually stretching restricted anterior pectoralis and shoulder muscles.

The goals of core training include improving dynamic postural control, establishing optimal muscular balance and joint movement around the complex, maximizing functional strength and endurance, and increasing postural control (25). Core stabilization also provides proximal stability in the spine for more efficient movement in the lower extremities.

Common muscle impairment patterns seen with many acute and chronic low back pain patients include weak buttock muscles (i.e., gluteus medius), weak abdominals (rectus and transverse abdominus), overactive synergist muscles such as piriformis and hamstring, and shortened antagonist muscles (thigh adductors and iliopsoas) (26). In the cervical spine, many neck pain patients present with weak trapezius and scapular muscles, overactive levator scapulae, and shortened antagonists, such as the pectoralis. They often show maladaptive postures and positions of the cervical spine. All of these impairments may contribute to pain and disability and may be specific areas of assessment and treatment by the properly trained therapist. A therapy program could include strengthening exercises on an exercise ball or without specific equipment.

Mechanical Diagnosis and Therapy (McKenzie Therapy)

Mechanical diagnosis and therapy, commonly referred to as McKenzie therapy, is a common, specialized approach in which specially trained therapists instruct patients through a number of active positions of motion in the lumbar spine and determine whether patients are able to decrease or change the pain referral pattern from the extremities to more “centralized” low back or neck pain. This is based on the theory that an intact nucleus pulposus (cervical or lumbar), responsible for generating referred pain to a limb, will produce different symptoms in certain positions with repeated standardized end range test movements (e.g., lumbar extension [seated or standing], lumbar flexion, side bending). The most common movement is lumbar extension, although a small percentage of patients may “centralize” their symptoms with repeated flexion or trunk side bending. Those patients who respond to repeated positioning (such as lumbar extension, flexion, or side bending) are given those same exercises to do on a daily basis to help decrease symptoms (27,28).

OCCUPATIONAL THERAPY (OT)

OT consists of assessment and training of patients in areas related to functional activities. Areas addressed may include specific activities of daily living (ADLs), posture, ergonomics, and body mechanics. Work site analyses may be conducted. Patients may be fitted for braces and splints. In the United States, occupational therapy may be provided in postoperative orthopedic care, such as after carpal tunnel release or upper limb fracture. An occupational therapist assesses range of motion, strength, and strength with an emphasis on improving functional, vocational, avocational (leisure), or sports-specific activities.

Posture and Body Mechanics

Many chronic musculoskeletal pain conditions of the cervical and lumbar spine, large joints (shoulder, hip), small joints (hand, wrist, ankle), and soft tissue structures (i.e., tendon, muscle, and ligaments) may be aggravated by poor posture. Basic assessment of sitting and standing posture and retraining may be a focus of individual OT sessions and can be applied at home and work. Proper standing and sitting posture will help reduce stress and strain over bony and soft tissue structures.

Body mechanics assessment and retraining can be an important clinical focus of OT in many chronic pain conditions. Proper lifting and reaching mechanics, similar to posture training, can help to improve function, decrease pain, increase tolerance for an activity, and limit injury. Simple instructions to patients to improve posture and decrease pain are included below:

Standing:

Feet shoulder width apart, shoulders even over hips

Even weight distributed over both feet

Knees straight and unlocked

Pelvis level Stomach muscles slightly engaged

Ears lined up over shoulders

Sitting:

Pelvis level, and weight is even over ischial tuberosities

Hips and knees at 90 degrees or greater

Knees and feet shoulder/hip width apart

Feet flat on floor or stable surface

Knees over ankles

Stomach muscles slightly engaged

Shoulders evenly aligned over hips (29)

Ergonomics is the science of designing equipment with the aim of increasing productivity and reducing fatigue and discomfort. This is an additional area in which OT can be of value to a patient with chronic pain. With the increased use of computers, keypads, handheld devices, and prolonged sedentary work, mostly on a computer, there has been an increase in chronic neck, shoulder, upper limb musculo-skeletal conditions, as well as low back pain. An ergonomic evaluation helps the OT to optimize positioning of equipment, keyboards, and other work site tools to help improve function and tolerance, decrease pain, and prevent injury. Physical rehabilitation programs that include ergonomic interventions for upper limb and neck pain have been found to be effective in decreasing pain and improving function in a number of studies (30,31). See figure on proper sitting/ computer setup.

Occupational Work Rehabilitation

OT can assist in addressing patient-specific work goals. Occupational therapists can review job descriptions, perform job site analyses, and thereby help to determine whether job site or specific job modifications are needed to enable a worker or patient to perform a job safely. Occupational therapists can perform functional baseline testing to clarify an individual’s specific physical abilities and tolerances or can provide more structured and extensive testing via a functional capacity evaluation (FCE) (32). FCEs are done by specially trained physical or occupational therapists and usually take place over a 3- to 4-hour period. They help determine physical tolerances for lifting, pulling, and pushing capabilities and are typically integrated with validity testing (33). The FCE can help to determine whether a patient can meet specific job demands as defined by the U.S. Department of Labor (34). Work or physical demand levels include sedentary, light, medium, and heavy and clarify both the amount of time an activity is done (i.e., infrequent, occasional, frequent, and constant) as a percentage of the work day as well as the frequency of repetitions (see Table 95-1).

TABLE 95-1 DICTIONARY OF OCCUPATIONAL TITLES SYSTEM FOR CLASSIFYING THE STRENGTH DEMANDS OF WORK

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A general familiarity with physical demand levels is helpful to the clinician when asked to determine work restrictions for patients and safety for return to work. Formal FCE testing may also provide objective measures for documenting inconsistencies of effort, validity of effort, and responses to work (i.e., heart rate, blood pressure).

PSYCHOLOGICAL INTERVENTIONS AS PART OF A PAIN REHABILITATION PLAN

In addition to physical and occupational therapy, pain rehabilitation relies heavily on psychological interventions (35). The reader is referred to the chapter on psychological therapies for pain (Dr. Covington). The table below summa-rizes the range of psychological interventions that may be incorporated into a focused treatment plan or more comprehensive multi- or interdisciplinary treatment program (36) (see Table 95-2).

TABLE 95-2 PSYCHOLOGICAL INTERVENTIONS FOR PAIN REHABILITATION MANAGEMENT

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From Kerns R, Sellinger J, Goodin B. Psychological treatment of chronic pain. Annu Rev Clin Psychol 2011;7:411–434.

MODALITIES USED IN ACUTE AND CHRONIC PAIN CONDITIONS

Passive PT (Modalities)

The final section will overview passive modalities commonly used for acute musculoskeletal and soft tissue injuries and in carefully selected chronic pain cases. It includes heat and cold therapies; ultrasound; electrical stimulation, including transcutaneous electrical stimulation (TENS) and iontophoresis; and soft tissue massage. These passive modalities should be used judiciously to augment an active self-management program (see Tables 95-3 and 95-4).

TABLE 95-3 SUPERFICIAL AND DEEP HEAT MODALITIES

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From Stanos SP, et al. Physical medicine rehabilitation approach to pain. Anesthesiol Clin 2007;25:740–741.

TABLE 95-4 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS)

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From Stanos SP, et al. Physical medicine rehabilitation approach to pain. Anesthesiol Clin 2007;25:740–741.

Heat Therapy

Thermal modalities have often been used for soft tissue dysfunction and to assist with pain management for many years. Physiologically, heat applied to soft tissues produces an elevated temperature and an increase in blood flow to the affected region. With increased blood flow, hydrostatic pressure and increased capillary permeability lead to an increase in inflammatory mediators in the region, serving an important role in early healing. It is important for the practitioner to note that heat to affected regions is contraindicated in edematous regions, as heat can exacerbate this (37).

Pain relief from heat therapy is due to vasodilation in the affected region. This reduces muscle spasms, allowing for a greater tolerance in connective tissue stretching (38). The transfer of heat can be accomplished through conduction (hot packs, paraffin baths), convection (flu-idotherapy, hydrotherapy), and conversion (radiant heat). There are two types of heat modalities commonly used: hot packs (also known as hydrocollator packs) and ultrasound therapy.

Hot Packs

Hot packs or hydrocollator packs contain silica gel. This silica gel is heated to a temperature of approximately 170°F in a hot water tank. The hot packs are subsequently wrapped in four to six layers of towels and applied to the affected region on the patient’s skin for 20 to 30 minutes. It is necessary to check the patient every 5 minutes during this procedure to avoid risk of burns (39). Indications for hot pack application include painful muscle spasms, abdominal muscle cramping, menstrual cramps, and superficial thrombophle-bitis. Contraindications of hydrocollator therapy include peripheral vascular disease, superficial skin eruptions at the site of application, desensitized skin, altered sensation in the affected region, or new skin (40).

Ultrasound

Ultrasound provides the deepest heat of all of the heat therapy modalities used. Therapeutic ultrasonography uses a frequency range of 0.8 to 1.0 MHz. This is achieved by applying electrical energy to a crystal, which vibrates at a high frequency, thus producing ultrasonic waves. These can be delivered by pulsed or continuous methods, thereby providing a high heating intensity to the affected area. The ultrasonic waves vibrate tissues deep inside the affected region, creating heat that increases blood flow into the tissues, assisting with the healing process (41). Ultrasound is used to treat joint and muscle sprains, bursitis, and tendonitis. In addition to causing increases in tissue relaxation, local blood flow, and scar tissue breakdown, ultrasound can also be used to help reduce local swelling and chronic inflammation (42).

Ultrasound can also be used in phonophoresis, in which ultrasound is used to drive a topical agent, such as diclof-enac, into the tissues (43). The agent can be mixed with the ultrasound gel and applied under the ultrasound head, where the ultrasonic sound waves drive the medication into the tissues, potentially reducing inflammation and related pain.

Typical ultrasound treatments last from 3 to 5 minutes, depending on the size of the affected area. The dosage of the ultrasound is determined by the intensity and duration of stimulus. The intensity of sound energy available from the ultrasound head is typically expressed as watts per square centimeter. In acute conditions, low-intensity treatment is required. Chronic conditions may require a higher intensity. Indications for ultrasound include joint contractures, joint adhesions, calcific bursitis, neuromas, fibrosis, phantom limb pain, and myofascial pain (44). Contraindications for ultrasound include pregnancy, laminectomy sites, and ischemic regions. Application of ultrasound over surgically implanted hardware remains an area of controversy and should be performed with caution (45). Paraffin baths are another form of heat therapy utilizing conduction and are useful in contractures due to rheumatoid arthritis, burns, and scleroderma. Paraffin can be applied to the patient’s extremities. Since the specific heat of paraffin is one-half that of water, a higher temperature (55°C) is tolerable without risk of tissue burns when using paraffin compared to water (42°C to 45°C). Solid paraffin forms a protective and insulating coat over the skin, and the paraffin bath is maintained at the melting point of 51.7°C to 54.4°C in an insulated, thermostatically controlled container (46). Methods of paraffin bath application involve dipping, immersion, brush application, pouring, and casting/wrapping (47).

Cold Therapy

Superficial treatments with cold and pressure have long been used in treating painful conditions. Cryotherapy, or the use of cold, is used by therapists using superficial agents that are inexpensive and easy to use. These include ice, cold water, vaporizing liquids, refrigerated units, and chemical packs, often requiring little preparation on the part of the practitioner (48). Historically, cold therapy has been used more than heat in the acute phase of tissue injury. Application of cold to an affected body part in the acute phase can decrease the extent of tissue injury through decreasing nerve transmission in pain fibers, reduction in neurogenic inflammation, and causing the release of endorphins to the site of injury thereby raising the pain threshold (49,50). By cooling the surface of the affected region and underlying tissues, cold therapy results in blood vessel narrowing, or vasoconstriction, thus leading to a decrease in the amount of blood being delivered to the site of injury and decreasing the amount of soft tissue swelling. After several minutes, the blood vessels then dilate allowing blood to return to the region. Muscular spasm often occurs in response to pain, and ice has been shown to reduce this. It reduces the conduction velocity of sensory and motor nerves, thereby ultimately reducing motor activity (51). In addition, the risk of cell death due to increased oxygen demands during tissue injury is reduced by cold therapy, which reduces the oxygen requirements of cells in the affected region (52).

Ice pack treatment begins with placement of a dry terry cloth towel over the region to prevent direct contact of the ice with the skin. The ice pack is then applied to the affected region for no more than 20 minutes. Studies have shown that application of an ice pack containing at least 0.6 kg of ice leads to more cooling than does a 0.3-kg ice pack. When applied for 20 minutes to the painful region, the 0.6-kg ice pack produced a mean skin temperature of 6.0°C, compared to 9.6°C with the 0.3-kg ice pack. Thus, clinicians should consider using ice packs weighing at least 0.6 kg for cold treatment (53).

Another method of cold therapy is ice baths, which are fashioned by filling a tub half way with cold water and ice and submerging the injured body part into the tub. The disadvantage of ice baths is that no compression is involved (RICE principle—rest, ice, compression, and elevation) (54).

Ice massage is another cold therapy modality in which water is placed into a foam cup and frozen. The top of the cup is then peeled back, and ice is massaged into the painful region using a constant circular motion. It is important to avoid holding the ice in one area for more than 3 minutes in order to prevent frostbite. This method can be repeated two to three times daily.

Gel packs can be an effective method of cold therapy because they are reusable and portable. They are useful in the clinic setting because they are a clean means of providing cold therapy. Gel packs are applied to the affected region through a towel or cloth to prevent frostbite.

Another cold modality, vapocoolant sprays, effectively remove heat from skin by evaporating quickly when in contact with the affected body part. This method of cold therapy only provides a very superficial cooling effect but is often used before a contracted muscle is stretched (commonly referred to as the “spray and stretch technique”) (55).

General indications for cold therapy include acute mus-culoskeletal trauma, pain, muscular spasm, and spasticity. Precautions and contraindications for cold therapy include ischemia, cold intolerance, Raynaud phenomenon, cold allergy, and skin insensitivity (56).

Electrical Stimulation Therapy

Electrical stimulation is a nonpharmacologic physical modality, which has been shown to strengthen muscles, promote healing, increase circulation to affected tissues, and ultimately reduce pain. This modality has been shown to be efficacious for a variety of pain conditions, including chronic low back pain, hemiplegic shoulder pain, and arthritic pain (57). With TENS therapy, a current generator delivers electrical current through electrodes applied to the body causing a tingling sensation and/or muscle contractions. This electrical signal disrupts the pain signals being from the affected area (58).

Transcutaneous Electrical Nerve Stimulation (TENS)

This type of electrotherapy applies a low-voltage electrical pulse to the nervous system using surface electrodes placed onto the skin in the affected area. TENS has been used in both acute and chronic pain states with the goal of pain reduction. The analgesia produced by TENS has been explained by the Gate-Control Theory of Pain, developed by Melzak and Wall in 1965. In this theory, it is believed that TENS decreases pain by stimulating large, highly myelinated afferent A-beta fibers, which then block or gate the transmission of pain signals through small nociceptive fibers (myelinated A-δ and unmyelinated C fibers) at the level of the spinal cord, that is, by increasing the activation of A-beta fibers. TENS “closes the gate” or decreases neuronal transmission in the spinal cord, resulting in decreased pain (59).

The electrodes used in TENS are typically placed over the regions where pain is perceived. While different types of stimulation devices are available, the most common type of stimulation has been high-frequency (40 to 150 Hz) and low-intensity (10 to 30 mA) stimulation, with the amplitude adjusted to result in minimal discomfort to the patient. This type of stimulation is known as conventional mode TENS (in contrast to low-frequency/high-intensity stimulation). Patients are instructed to place the electrodes over the affected regions and set the TENS unit at a comfortable amplitude for 30-minute intervals, two to three times daily.

While the use of TENS is common, studies of efficacy have shown conflicting results. One study by Oosterhof et al. (60) found a statistically significant difference between conventional and sham TENS, in which the conventional TENS group had higher rates of patient satisfaction; however, no statistically significant differences in pain intensity were found between the two groups. In another study focusing on the use of TENS in diabetic neuropathic pain, no statistically significant differences in pain relief were found when TENS was compared to placebo (61). In a systematic literature search, the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology found two class II studies showing benefit of TENS versus sham treatment in chronic low back pain, but two class I studies and another class II study not showing benefit. The committee concluded that TENS is ineffective for chronic low back pain, but probably is effective for painful diabetic neuropathy (two class II studies) (62). The only common adverse effects are intolerance of the sensation of stimulation and skin irritation, which is likely if the intensity of the unit is too high. This can be rectified by frequently shifting electrode positions as well as using a different conducting gel (63).

Precautions and Contraindications of Transcutaneous Electrical Nerve Stimulation (TENS) Therapy

Electrical stimulation therapy should be avoided over regions such as the heart and anterior cervical region or in patients with malignancies. Electrodes should never be placed on or near the eyes, in the mouth, transcerebrally, or on the front of the neck. Electrical stimulation should not be used during pregnancy or at any time around infected tissue. In addition, this type of therapy should not be used by individuals with pacemakers, defibrillators, or other implanted electrical devices due to potential for interference and failure of the pacemaker itself as well as the potential of defibrillator/ electrical device discharge (64). Caution should be utilized when employing electrical stimulation over insensate skin, as this can cause superficial or more serious burns.

Iontophoresis

Iontophoresis uses TENS therapy to drive topical medications, such as dexamethasone, into the affected tissues (65). This is followed by attaching a TENS unit to the region, and a current of 2 to 4 mA is applied for approximately 10 minutes. Once this process has been completed, the electrical pads are removed, and the area is cleaned. By working as a percutaneous drug delivery system, iontophoresis allows drug delivery directly to the target region. In addition, iontophoresis avoids the risks and inconveniences of parenteral therapy, prevents the variation in the absorption and metabolism seen with oral medication administration, and effectively bypasses hepatic “first-pass” elimination commonly seen with oral medication administration (66). Typical medications used with iontophoresis include topical steroids and other nonsteroidal anti-inflammatory medications (67). Clinical applications of iontophoresis include conditions such as bursitis and plantar fasciitis.

Massage Therapy

Massage therapy involves pressure and stretching provided in a rhythmic fashion to affected regions for approximately 5- to 15-minute duration. The physiologic effects include reflex vasodilation with improvement in circulation, assistance in venous blood return from the periphery to the central nervous system, increased lymphatic drainage, decreased muscular tightness, and softening of adhesions/ scars (68). There are several types of therapeutic massage, including effleurage, petrissage (kneading), tapotement (percussion), friction massage, soft tissue mobilization (forceful massage of the fascia–muscle system), myofascial release, and acupressure (Table 95-5). Please refer to the table below for a description of each type of massage (69).

TABLE 95-5 MASSAGE THERAPY TECHNIQUES

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Today, we have extensive data from the Ottawa Panel, which investigated several studies employing the usage of massage to treat several pain syndromes. The Ottawa Panel was able to demonstrate that massage therapy showed beneficial results for mechanical low back pain when compared to acupuncture, self-care/education, relaxation therapies, conventional physiotherapy, and placebo. In addition, the Ottawa Panel determined that massage therapy should be recommended when managing subacute and chronic low back pain for immediate posttreatment improvement in pain and disability and short-term relief when combined with therapeutic exercise and education (70).

Massage should not be performed over areas containing malignancies or over infected areas or regions containing nerve entrapments. Additional contraindications include presence of deep venous thromboses, severe varicosities, severe clotting disorders, and anticoagulation (71).

CONCLUSION

The patient with a prior or current substance abuse disorder and comorbid chronic pain can benefit from a wide array of active therapeutic interventions including physical and occupational therapies, passive modalities for acute and some chronic pain conditions, and participation in more comprehensive multi- and interdisciplinary treatment programs. The focus of care, as in substance abuse treatment, should encompass a biopsychosocial multimodal approach. Psychological interventions, including behavioral, cognitive–behavioral therapy, mindfulness training, and acceptance- and commitment-based therapies, may be integrated into rehabilitation-based programs.

In some patients, the use of passive modalities may be used as an additional tool for treating acute musculoskeletal and soft tissue disorders or for ongoing maintenance management of chronic pain. The active and passive treatment modalities and more formal multi- and interdisciplinary treatment interventions reviewed in this chapter can be easily integrated into an ongoing treatment program of patients with substance abuse and addiction disorders. In more challenging cases, the addiction specialist can refer patient to their colleagues in physical medicine and rehabilitation, occupational medicine, and pain medicine. Patient referral to physical and occupational therapy should include follow-up and monitoring for compliance, assessing the ability for the patient to incorporate skills learned in treatment into their daily lives and during flare-ups. Better self- management of pain may help to reduce pain, improve psychosocial functioning, and, in many instances, help to reduce the incidence of recurrence of addictive behaviors and relapse.

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