Volume V, Issue 3, November 1997

Physical Rehabilitation in Managing Pain

Pain that commonly follows injury or illness can impair physical, psychological, social,
and vocational functions1. The International Association for the Study of Pain has
emphasized the need for multidisciplinary management of patients with chronic pain and
for attention to the physical, psychological, social, vocational, recreational, and other
functional aspects of persons with pain-related disability2.

Approaches to managing pain include: (1) surgical/anesthesiological; (2)

pharmacological; (3) physical rehabilitative; (4) psychological; and (5)
alternative/complementary. Historically, the use of physical agents to treat pain and other
impairments has been empiric. Recent advances in neurophysiology and modulation of
pain and its perception provide a clearer rationale for the use of physical agents for
rehabilitation of patients with pain and related disability3,4.

Developed countries have emphasized pharmacological, surgical, interventional, and

advanced anesthetic approaches for pain management. Psychological/behavioral and
cognitive methods are being increasingly utilized, especially in comprehensive pain
centers.

In countries with limited resources, including the United States under managed care,
physical agents merit consideration as first-line treatment. Every clinician involved in
management of patients with pain should understand the rationale for these techniques3,6.
They frequently reinforce pharmacological and psychological approaches and play a key
part in "reactivating" patients with disuse, deconditioning, depression, and disability that
are out of proportion to the pathology of their chronic pain6,7.

Physical rehabilitation emphasizes the use of modalities such as heat, cold, and
electricity, and hands-on techniques such as manipulation, mobilization, massage, and
traction. It also involves planning so as to balance rest for the injured part, prevention of
reinjury through use of orthotic devices (braces, corsets, and splints), and strengthening
by specific exercise programs6 (Table 1). Physical methods of pain control can aid in
aggressive mobilization and nonsurgical rehabilitative treatment of patients with acute as
well as chronic pain3,6,8,9.

Table 1. PHYSICAL REHABILITATION INTERVENTIONS

- Prevent reinjury/provide support: orthotics (braces, corsets, splints)

- Physical modalities, heat, cold electricity

- Traction

- Manual techniques: mobilization, massage, manipulation

- Exercise: aerobic conditioning, specific exercises

Heat, one of the oldest modalities to relieve pain, can also decrease muscle spasm and
improve function (Table 2). Superficial heat can be provided by means of hot packs, hot
water bottles, hot moist compresses, electrical heating pads, or chemical or gel packs8,10,11.
It can also be provided through immersion in water (hydrotherapy) such as through
whirlpool, Hubbard tank, or heated pools. All these modalities convey heat by conduction
or convection. Superficial heat elevates the temperature of tissues and provides the
greatest effect at 0.5 cm or less from the surface of the skin10,11.

Table 2. THERAPEUTIC HEAT

SUPERFICIAL

- Hot pack, hot water bottle, moist compress

- Heating pad: electric, chemical or gel pack
- Hydrotherapy: whirlpool, heated pool
- Fluidotherapy

DEEP
- Diathermy: shortwave, microwave
- Ultrasound

Deep heating (diathermy) is achieved by converting another form of energy to heat. In

shortwave diathermy, high-frequency electrical currents are converted to heat, while
microwave diathermy uses electromagnetic radiation as the source. Ultrasound, first
introduced for medical use in the United States in the late 1940s, uses high-frequency
acoustic vibration that is converted into heat. Deep-heating modalities increase
temperature to depths of 3–5 cm8,10. Ultrasound is the preferred treatment in most painful
disorders, especially those arising from soft tissues and ligaments, as it has greater
penetration and also nonthermal effects, such as increasing extensibility of tissues8,10,11.
All these modalities require specialized equipment and trained professionals.
Physiological effects of heat (Table 3) include analgesia, increased flexibility of
collagenous tissues, and reduction of muscle spasm through selective decrease in
excitation of nociceptive nerve endings. Increased muscle temperature also decreases
spindle sensitivity and reduces "muscle spasm." Heat increases blood flow to the warmed
area, which also may accelerate healing.

Table 3. PHYSIOLOGICAL EFFECTS OF

HEAT

- Relief of pain
- Increase in flexibility of collagenous tissues
- Reduction of muscle spasm
- Increase in blood flow
- Mental relaxation

Because heat increases extensibility of collagen tissues, it may be helpful before

stretching exercises of shortened muscles prior to strengthening4,6. For example, in
patients with adhesive capsulitis ("frozen shoulder") or postsurgical scarring, ultrasound
followed by deep massage and stretching is effective in rehabilitation treatment. The
analgesic effects of heat may be explained by the gate control theory of pain
modulation4,5.

Superficial heating modalities have advantages over diathermy as they can easily be used
at home and provide independence and self-control to patients. Heating pads,
hydrotherapy, infrared lamps (sunlamps), hydrocollator packs, and paraffin wax can
readily be used at home8,11.

A recent addition to superficial heating modalities is fluidotherapy. This device circulates

warm air through small cellulose granules under thermostatic control. The advantage of
this modality is its ability to provide superficial heating to an extremity without placing it
in a dependent position (as would be required in hydrotherapy) and thus to reduce the
potential for development of edema.

Microwave and shortwave diathermy techniques are contraindicated in the presence of

metal because metals selectively absorb energy and generate heat that can damage
surrounding tissues. Microwave diathermy also selectively heats tissue with high water
content and thus is contraindicated over joints with effusions or cavities with fluids.
Diathermy is generally contraindicated in areas of active malignancy10. Both shortwave
and microwave diathermy are contraindicated for patients with pacemakers8–10.
Ultrasound has the unique advantage of being safe around metal and useful over small
areas. It increases extensibility of tissue and thus is helpful in treating trigger points, tight
tendons, and capsular structures.

Cryotherapy
Application of cold is a common and practical treatment for pain (Table 4). Ice packs,
commercially prepared chemical gel packs, and cold packs are easily available and can be
used at home. Cold packs are usually applied for 15 minutes and are helpful because they
conform to body contours and produce comfortable and safe pain relief8. Ice massage, a
specific technique in which the skin is rubbed with a block of ice, produces three stages
of sensation. The patient first experiences coolness lasting a few minutes, followed by a
burning sensation for a few minutes, and then numbness and pain relief8. Ice massage is
particularly useful in treating small areas such a trigger points, tendons, and bursae, and
should precede massage and stretching programs.

Table 4. CRYOTHERAPY

- Cold packs
- Ice massage
- Ethyl chloride (vapocoolant spray)
- Fluoromethane (vapocoolant spray)

The use of ethyl chloride and fluoromethane, both vapocoolant sprays, has been
popularized in the treatment of myofascial trigger points. While the involved muscle is at
passive stretch, the trigger point and referred area of pain are sprayed in unidirectional
parallel sweeps. This application is usually followed by slow steady stretch of the
muscle12.

Cold is the immediate treatment of choice after acute injuries and is also used to
inactivate trigger points after a muscle is injected. Cold relieves pain and decreases the
inflammatory response and associated swelling. It also reduces local metabolic activity of
underlying tissues, slows nerve conduction and, by its direct effect on muscle spindle
activity, reduces muscle spasm and guarding8,10. Cold therapy is contraindicated for any
medical condition in which vasoconstriction will increase symptoms, such as certain
connective tissue disorders and Raynaud’s phenomenon, and in some patients with
hypersensitivity to cold that manifests as a histamine-like response.

Electrotherapy

Electricity has been a pain treatment modality since ancient times when "torpedo fish"
that produced electric currents were used to treat gout and headaches. Today the most
common mechanism for applying therapeutic electricity is transcutaneous electrical nerve
stimulation (TENS). Electrogalvanic stimulation (EGS), electrical muscle stimulation
(EMS), focus stimulation, and neuroaugmentative stimulation are other rehabilitative
methods that employ electrical current.

TENS involves the delivery of electrical energy across the surface of the skin to stimulate
the peripheral nervous system. The rationale is based on the gate control theory of pain
modulation4,5. The efficacy of TENS has been documented in anecdotal and controlled
studies. Used in acute pain control, it promotes early and aggressive mobilization and
rehabilitation. TENS is most effective in neuropathic pain such as complex regional pain
syndromes (reflex sympathetic dystrophy and causalgia), phantom pain, and postherpetic
neuralgia. Empirical and experiential evidence indicates that TENS, in selected patients,
can provide an alternative to medications and improve the individual’s function6,7,13.
However, several trials and systematic reviews indicate that a large, perhaps major,
component of pain relief after TENS is due to a placebo effect.

Traction

Tissues may be mechanically distracted manually or with equipment. The rationale is to

provide mechanical distraction of vertebral bodies and facet joints to reduce pain from
nerve irritation. Traction thus is useful to treat cervical radiculopathy, and to a lesser
extent, lumbosacral radiculopathy11. Traction also stretches soft tissues and facilitates in
breaking the "pain-tightness-pain" cycle. Traction can be applied in physical therapy
centers for a few sessions and then transferred to home use. Newer devices for cervical
traction are effective and simple to use, and more easily transferable to the home than
prior overhead cervical traction equipment.

Manual Therapy

Manual therapy includes techniques that use a "hands-on" approach such as massage
(stroking, friction, kneading), manipulation, and mobilization9,11.

Massage includes stroking, friction, and kneading of muscles and soft tissues. Stroking
massage decreases edema and produces relaxation of muscle, while friction and kneading
massage break down intramuscular adhesions and prepare the muscles and soft tissues for
stretching. They are effective in reducing edema, stiffness, and pain, especially in
myofascial trigger points. Massage can be taught to patients and family members for
home use9.

Mobilization includes techniques in which a trained physical or occupational therapist

uses a manual approach to handle tissues including muscles and fascia. Myofascial
release is a method of soft tissue mobilization that focuses on the fascial component,
which is believed to cause pain and dysfunction.

Manipulation is a skilled, passive movement of a spinal segment, usually within and

occasionally beyond its active range of motion. Various medical professionals, including
osteopathic physicians, chiropractors, and primary care physicians, use spinal
manipulation but differ in rationale and techniques used.

Therapeutic Exercise

The most important element of physical rehabilitation addresses improvement in function

through therapeutic exercises designed to increase functional activity. Although initial
rest may he helpful after an acute injury, few studies recommend rest beyond several
days. Prolonged bed rest leads to many deleterious physiological effects such as loss of
strength, stiffness, contractures, decreased cardiopulmonary endurance, and metabolic
changes. Exercises include range of motion, stretching, strengthening, general
cardiovascular conditioning, specific exercises, and relaxation exercises.

Table 5. THERAPEUTIC EXERCISES

- Range of motion/stretching
- Strengthening
- Cardiovascular aerobic conditioning
- Specific exercises
- Relaxation exercises

Range of motion (ROM) exercises increase and preserve joint range of motion. They can
be done passively by a physical therapist or family member, actively by the patient, or
can be active-assistive, when the patient performs the range of motion while assisted by
another person who increases the ROM with gentle stretch. ROM exercises increase
elasticity of soft tissue, especially when accompanied by gentle stretch. Muscles that
cross two joints such as the hamstrings, gastrosoleous group, hip flexors, pectorals, finger
flexors and extensors, and paraspinal muscles frequently become tight and shortened,
causing poor posture and pain. Stretching these muscles with ROM exercises improves
body mechanics, posture, and function. ROM and stretching exercises should be preceded
by application of heat and are transferable to a home program6.

Strengthening Exercises

These exercises can be done isometrically, in which muscle length is unchanged but
tension is increased, or isotonically, by active contraction of the muscle with ROM
against resistance. Isometric exercises incorporate gradual increases in resistive force and
repetitions. Most strengthening exercise programs can be taught to patients for continued
use at home.

General cardiovascular conditioning exercises involve the whole body and increase
aerobic capacity. They increase physical capabilities, reduce pain, and increase
endurance6,7,9. A combination of ROM, stretching, flexibility, strengthening, and aerobic
exercise is an essential part of physical rehabilitation to significantly improve function of
patients deconditioned by effects of chronic pain.

Specific exercise protocols have been proposed for different clinical conditions. The
Williams flexion exercises recommended in the 1950s were replaced by McKenzie
extension exercises in the 1980s and by combined lumbar stabilization exercises in the
1990s6. Controversy remains, but most authors agree on the benefits of combined aerobic
conditioning, stretching, and fitness exercises to increase flexibility, posture, and
endurance. Aerobic exercises such as walking on a treadmill, riding a stationary bicycle,
or swimming are rhythmic, repetitive, dynamic activities which use large muscle groups.
Detailed discussion of the variety of systems of and employment for muscle
strengthening is beyond the scope of this paper.
A program that combines range of motion, stretching, flexibility, strengthening,
general aerobic exercise, and relaxation is necessary to improve function of patients
deconditioned by effects of chronic pain.

Relaxation exercises are beneficial to reduce anxiety, autonomic hyperactivity, and

muscle tension, all seen in chronic pain states. Techniques such as imagery, progressive
muscle relaxation, controlled breathing, or listening to relaxation tapes are commonly
used in programs designed to manage chronic pain. Their adaptability for use at home
and in other environments is another advantage.

Pain rehabilitation is an integrated process that addresses medical management and treats
the physical, psychological, social, vocational, emotional, and legal aspects of persons
with acute and chronic pain. The physical rehabilitation techniques described, in addition
to appropriate pharmacological, anesthesiological, surgical, and psychological/behavioral
approaches, will enhance independence and functional ability in persons with pain-
related disability. Every clinician treating patients with pain should have a good
understanding of physical rehabilitation approaches in the comprehensive management of
pain and related disability.

Every clinician treating patients with pain should have a good understanding of
physical rehabilitation approaches in the comprehensive management of pain and
related disability.

Sridhar V. Vasudevan, MD
Department of Physical Medicine and Rehabilitation
Medical College of Wisconsin
Milwaukee, Wisconsin, USA

References

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2. Loeser JD, et al. Desirable characteristics for pain treatment facilities [guidelines]. Seattle: IASP,
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4. Fields HL, Basbaum AL. Am Rev Physiol 1978; 40:217–248.
5. Melzack R, Wall PD. Science 1965; 150:971–979.
6. Vasudevan SV. Current Review of Pain 1994; 130–140.
7. Brena SF, Chapman SL. Management of Patients with Chronic Pain, Great Neck, NY: PMA
Publications, 1983.
8. Michlovits S. Thermal Agents in Rehabilitation. Philadelphia: F.A. Davis, 1986.
9. Kottke FJ, Lehmann JF (Eds). Krusens Handbook of Physical Medicine and Rehabilitation, 4th
ed. Philadelphia: W.B. Saunders, 1990.
10. Lehmann JF, deLateur BJ. Ultrasound shortwave, microwave, superficial heat, and cold in the
treatment of pain. In: Wall PD, Melzack R (Eds). Textbook of Pain. Edinburgh: Churchill
Livingstone, 1984, pp 717–774.
11. Leek JC, et al. Principles of Physical Medicine and Rehabilitation. Orlando: Grune and Stratton,
1982, 275–350.
12. Travel JJ, Simons DG. Myofascial Pain & Dysfunction - The Trigger Point Manual, Vol. 1 and
2, Baltimore: Williams and Wilkins, 1983.
13. Manheimer JS. TENS: uses and effectiveness. In: Michel TH (Ed). Pain. New York: Churchill
 Livingstone, 1985, pp 73–121.
14. Maigne R. Am J Phys Med Rehabil 1987; 44:55–59.

Supported by an educational grant from l'Institut de la Douleur, Paris, France

Disclaimer: Timely topics in pain research and treatment have been selected for publication but the
information provided and opinions expressed have not involved any verification of the findings,
conclusions, and opinions by IASP. Thus, opinions expressed in Pain: Clinical Updates do not necessarily
reflect those of IASP or of the Officers or Councillors. No responsibility is assumed by IASP for any injury
and/or damage to persons or property as a matter of product liability, negligence, or from any use of any
methods, products, instruction, or ideas contained in the material herein. Because of the rapid advances in
the medical sciences, the publisher recommends that there should be independent verification of

EDITORIAL BOARD

Editor-in-Chief: Daniel B. Carr, MD, Internal Medicine, Endocrinology, Anesthesiology, USA

Consulting Editor: Howard L. Fields, MD, PhD, Neurology, Neuroscience, USA
Editors:
Eduardo Bruera, MD, Oncology, Palliative Care, Canada
James N. Campbell, MD, PhD, Neurosurgery, Neurobiology, USA
Per Hansson, MD, PhD, DDS, Neurology, Odontology, Sensory Physiology, Sweden
Mark J. Lema, MD, PhD, Anesthesiology, Cancer Pain, USA
Robert G. Large, MB BCh, Psychiatry, New Zealand
Laurence E. Mather, MSc, PhD, Pharmacology, Australia
Christine A. Miaskowski, RN, PhD, Oncology Nursing, Quality Assurance, Opioid Pharmacology, USA
Philippe Poulain, MD, Anesthesiology, Cancer Pain, France
Barbara S. Shapiro, MD, Pediatrics, USA
Christoph Stein, MD, Neurobiology, Anesthesiology, Germany USA
Dennis C. Turk, PhD, Psychology, USA
Production Editor: Leslie Nelson Bond

Copyright © 1997, International Association for the Study of Pain. All rights reserved.