The goals of rehabilitation in patients suffering from acute or chronic pain can be quite variable. However, the foundation of successful rehabilitation always focuses on functional and analgesic optimization. Patients can have pain for a multitude of reasons and a proper diagnosis is essential in directing the appropriate rehabilitation protocol. Physical Medicine and Rehabilitation specialists utilize a comprehensive approach in diagnosing and managing patients with acute and chronic function-limiting or painful conditions.
A vast majority of patients suffering from pain will present for evaluation of low back, neck, or joint pain. Rehabilitation-based therapies include physical and occupational therapy, therapeutic exercise, modalities, manual therapies, and bracing. Ideal treatment of any one condition is likely to be multimodal and include both rehabilitation-therapies as well as other treatments such as oral medications, topical medications, or possibly interventional procedures which can help facilitate participation in rehabilitation treatments. It is also important to address both the psychological and behavioral aspects of pain in addition to the physical impairments. As such, instituting a multidisciplinary, multimodal treatment plan will provide the most sustainable improvements in both pain and function.
Part 1: Therapies
The most fundamental component of pain rehabilitation is therapy. When considering a specific therapy prescription, it is essential to first establish an accurate diagnosis and to determine the goals of treatment. Although therapies can come in many shapes and forms, emphasis should always be placed on improving function and independence. Where acute and chronic pain exists, decline in function is typically seen. Therapies serve as a way to emphasize increased activity levels and/or encourage movement where it is often avoided. As such, improved function can be accompanied by both decreased pain levels and enhanced ability to cope with any persisting pain. Finally, it is important to set realistic goals. In cases where complete pain resolution may not be feasible, improving overall function should always be emphasized.
Physical Therapy is a discipline of rehabilitation medicine that aims to help individuals develop, maintain, and restore maximum body movement and physical function. The ultimate goal of physical therapy is to improve health and quality of life by enhancing mobility and balance, reducing pain, and preventing disability. Physical therapists use many techniques to improve strength, range of motion, and coordination, specifically catered to an individual’s medical condition. They also train patients to improve body mechanics that may be contributing to exacerbation of pain symptoms. Physical therapists may use modalities and manual techniques to facilitate rehabilitation which are discussed later in the chapter.
Occupational Therapy (OT) is another discipline of rehabilitation medicine that aims to enhance functional independence through therapeutic performance of activities of daily living. OT aims to enable people, including those with chronic pain, to overcome their ailments through maximizing individual functionality. Occupational therapists typically focus on fine and gross motor movements, particularly flexibility and coordination of the upper extremities. Occupational Therapists are especially adept at teaching energy conservation techniques and emphasizing ergonomics and posture to maximize function and minimize pain.
Psychology also plays a large role in rehabilitation. Specifically, pain psychology can play a pivotal role in an individual’s ability to overcome chronic pain. Pain is comprised of both sensory and emotional components that affect one’s perception of pain. Therefore, the interpretation of pain can be modified by regulating one’s thoughts and/or emotions. This principle is of utmost importance to pain rehabilitation and is a crucial component of the multidisciplinary approach to treating chronic pain. It should be noted that many patients suffering from chronic pain may be apprehensive about a psychological referral and are more likely to be willing to proceed with evaluation after receiving an appropriate explanation and rationale of treatments such as cognitive behavioral therapy (CBT) and mindfulness-based stress reduction.
Movement-Based Therapies
Introducing activity where it may otherwise be lacking is an important step in the process of overcoming both acute and chronic pain alike. Physiologically, movement and exercise do not directly reduce pain. However, it is clear that staying active plays an important role in reducing the musculoskeletal sequelae, including pain, which often accompanies inactivity. Relative rest should be emphasized in the acute inflammatory phase of an injury and physical activity should be rapidly reintroduced unless there is an obvious risk of structural damage. As the patient becomes more active, tolerance for functional activities increases and overall wellness typically improves.
McKenzie approach
The McKenzie Approach , is a popular standardized method to evaluate, treat and prevent low back pain that is typically used in patients with acute low back pain accompanied by radicular leg pain. A key component of the McKenzie Approach is to identify the directional preference of movement. This approach divides the diagnosis of back pain into three “syndromes”: (1) derangement, (2) dysfunction, and (3) postural.
- 1.
Derangement—the most common syndrome classification—the goal in this treatment is to perform exercises that cause centralization of radicular pain. Specifically, an individual with low back pain that radiates in the buttocks or leg can be taught to move the pain more proximally into the low back. This can be induced with the use of extension-based exercises and is a common choice of physical therapists when approaching back pain. This principal can be applied to other areas of the body as well. The figure below ( Fig. 14.1 ) is a visual representation of the McKenzie centralization phenomenon—the gradual movement of radicular symptoms (aka sciatica) to isolated low back pain.
Fig. 14.1
McKenzie centralization phenomenon (Musculoskeletal Key, 2017) .
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Dysfunction—determined by mechanical impairments and deformities of affected tissue within the body (e.g.,: scar tissue). Treatment is performed with the goal of remodeling the affected tissue via engagement/mobilizing through exercise.
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Postural—goal of treatment is to avoid improper end-range positions (e.g.,: slouching) by education and proper posture training.
Complimentary movement therapies
Several movement-based therapies have been found to be potentially helpful in the treatment of low back pain. More common activities, such as Pilates, yoga, and tai chi, already have strong participation among the general population. Lesser known techniques, such as Feldenkrais and Alexander, also offer significant utility in certain subsets of patients. While most of the research surrounding Pilates, yoga, and tai chi is characterized by inconsistent findings and significant variability among studies, the risk for potential harm is quite low with these forms of exercise and they should be considered as a recommendation for patients with chronic pain, especially low back pain .
Pilates
A form of core-strengthening exercises that emphasize proper form, muscle activation, and alignment. Although Pilates exercises were originally designed for performance artists, the beneficial effects have led to wider popularity in recent years. Several randomized studies have indicated the beneficial effects of Pilates on the treatment of back pain including lower disability scores and pain ratings after the intervention that are maintained at 1-year follow-up. However, it is unclear whether Pilates offers greater benefit than other forms of exercise.
Yoga
An exercise and lifestyle philosophy that promotes relaxation, breathing techniques, flexibility, and strengthening. Throughout the years, yoga has gained mainstream popularity and is a frequently chosen form of exercise for men and women alike. Yoga is commonly advocated as a treatment for musculoskeletal conditions including arthritis and back pain . Although there is some research indicating that yoga may be more beneficial than strength training, the evidence for yoga compared with other forms of exercise in the treatment of chronic back pain is mixed in regard to both improvements in pain and quality of life. However, a recent Cochrane systematic review in 2017 concluded that there is low to moderate evidence that yoga may provide low to moderate improvements in back-related function and may be slightly more effective for pain relief at 3–6 months when compared with no exercise at all. In addition, the same review noted that while yoga is associated with more adverse events when compared with no exercise, none of the events were considered serious and it was found to have the same risk of adverse events as other exercise modes for back pain. It remains unclear if adding yoga to existing exercise programs is more beneficial than exercise alone ( Table 14.1 ).
| Yoga | Pilates |
|---|---|
| Mental and spiritual well-being | Fitness and physical well-being |
| Breathing techniques | Strengthening |
| Flexibility | Core exercises |
| Meditation | Toning |
| Utilizes body weight techniques and simple props | Utilizes equipment such as medicine balls and free weights |
Tai Chi
Tai chi is a form of exercise dating back to ancient China, which emphasizes slow purposeful total body movements synchronized with breathing. It has been proposed to help with balance and fall prevention, flexibility, as well as cardiovascular fitness, particularly in elderly populations. Tai chi has also been favored over no exercise, backward walking, and jogging for chronic low back pain . In addition, some research has shown tai chi to be more effective than traditional physical rehabilitation for chronic pain .
Feldenkrais method
This technique was developed from the study of biomechanics and the interrelationship between muscle contraction and motion. Specifically, there are two complementary components of awareness through movement which consists of verbal cues to movement, and functional integration which involves touch to facilitate movement. The goal is learned mindfulness of unnecessary muscle contractions during routine motor patterns. This helps form new neuromuscular patterns of movement and leads to development of efficient and pain-free motion. Feldenkrais therapy can be performed by patients at any functional level and can even be performed in gravity-eliminated positions such as lying down.
Alexander technique
This technique is a psychophysical educational approach to improving balance, coordination, and ease of movement. Emphasis is placed on adjusting movement patterns built into everyday activities that may be unknowingly resulting in pain or discomfort. The technique involves examination of posture, breathing, and movement fluidity. There are three underlying principles: (1) an organism functions as a whole; (2) a person’s ability to function optimally is dependent on the relationship of the head, neck, and spine; and (3) body function is affected by habitual patterns of use.
Manual Techniques
Manual medicine refers to a variety of hands-on therapies ranging from gentle, passive joint stretching to forceful mobilization to enhance range of motion. These techniques are most commonly utilized to treat musculoskeletal disorders, particularly neck and low back pain. Many physicians and other providers use hands-on skills in their approach to treat acute and chronic pain. Understanding the indications, principles, applications, and potential complications of manipulation, traction, and massage is an essential component to prescribing the appropriate treatment. While there is some debate about the reproducible benefits of such treatments, there is no shortage of significant, subjective benefit to individual patients.
Doctors of Osteopathic Medicine (D.O.), Chiropractors (D.C.), and Physical Therapists are practitioners that most often utilize manual techniques. D.O.s are trained in the administration of osteopathic manipulative medicine (OMM), which is founded on the concept that the body possesses self-healing mechanisms and that structure and function are interrelated. The goal is to promote optimal structural alignment to allow for self-healing to take place. Chiropractic philosophy describes a fundamental relationship between overall health and the spine. Specifically, mechanical impairments of the spine are thought to impair health, and the corrections of spinal misalignment can bring about improvements in health.
Manipulation refers to the use of hands on a patient to encourage maximal, painless movement of the musculoskeletal system and to improve motion in restricted areas. The primary goal is to improve the function and well-being of the patient through reduction of pain and improved biomechanical range of motion. Techniques are evaluated for success based on comparison of structural evaluation before and after treatment.
The treatments vary in their anatomical area of focus or in the type of force utilized. Specific names of each technique or discrepancies in style may vary heavily based on region, provider, or discipline. However, classification of the techniques is most easily summarized as (1) soft tissue technique, (2) articulatory technique, or (3) mobilization with thrust.
Types of Manipulation
Soft Tissue Technique . The goal of soft tissue treatment is to mobilize muscles and fascia. The forces utilized are typically directed in a way that muscle fibers are stretched laterally or longitudinally. Forces are applied slowly and released slowly to avoid potentiating spasm or exacerbating painful symptoms. An experienced practitioner is capable of assessing the response of the tissue to treatment through palpation. While soft tissue treatment can be used as the primary treatment (such as with massage), it can also be used to facilitate movement of edema or lymphatic fluid, reduce/modify pain, or prepare an area for specific mobilization. This is similar to massage; however, the focus with soft tissue treatment is on moving tissue rather than relaxing muscles.
Articulatory Treatment . This technique involves the repeated movement of a joint within its anatomical planes of movement to increase range of motion. This type of treatment is frequently used in patients with decreased joint range of motion such as for adhesive capsulitis or frozen shoulder. Specific techniques such as Spencer’s technique and Mulligan’s technique are frequently used in patients with adhesive capsulitis, with existing research showing Mulligan’s technique to potentially be more effective than Spencer’s and traditional rehab at 6 weeks intervention. The force is described as “low velocity, high amplitude” and can treat deep musculature by targeting the origin and insertion sites of individual muscles.
Mobilization With Thrust. This technique is also referred to as HVLA (“high velocity, low amplitude”). Typically, these techniques are the quickest form of addressing restriction of joint motion. Specifically, a barrier is engaged and moved beyond a set point via a low amplitude (short distance) thrust. This is sometimes accompanied by an audible “pop.” The pop, although frequently sought after, has no effect on the treatment outcome.
The tissues should be prepared for thrusting technique. Soft tissue treatment is often a precursor to thrust technique. If the tissues are not properly prepared, it is more difficult to engage the barrier and more force is required. Most importantly, the patient must be relaxed. Often, the thrust is given during exhalation, as it is believed that the tissues are more relaxed and receptive to motion at that time. With improper administration, the force will be dissipated by muscles and fascia rather than the mechanical barrier. Understandably, this redistribution of energy can result in iatrogenic injury. Perhaps the most serious complication of cervical manipulation is stroke associated with vertebrobasilar artery dissection. While a majority of vertebrobasilar dissections occur in the absence of cervical manipulation (either spontaneously or after trivial trauma with common daily movements), the estimated risk for an adverse outcome after cervical spine manipulation ranges from 1 in 400,000 manipulations to 1 in 3.85 million manipulations. Additional complications are listed below ( Box 14.1 ).
Thoracic/Lumbar
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Cauda equina syndrome
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Lumbar pedicle fracture
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Lumbar/thoracic compression fracture
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Rib fracture
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Lumbar/thoracic disk herniation
Cervical
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Vertebrobasilar insufficiency/stroke
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Lateral medullary infarction
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Internal carotid artery dissection
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Cerebral infarct
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Cervical myelopathy
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Cervical radiculopathy
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Long thoracic nerve palsy
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Diaphragmatic palsy
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Central retinal artery occlusion
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Cervical fracture/dislocation
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Epidural hematoma
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Intervertebral disk herniation
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Tracheal rupture
Various contraindications to HLVA exist. The most common and important to remember include atlantoaxial (C1–C2) ligamentous instability. Patients with rheumatoid arthritis and those with Trisomy 21 are particularly vulnerable. Additional contraindications are listed in Boxes 14.2 and 14.3 .
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Unstable fractures
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Severe osteoporosis
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Multiple myeloma
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Osteomyelitis
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Primary bone tumors
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Paget disease
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Any progressive neurologic deficit
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Spinal cord tumors
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Cauda equina compression
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Central cervical intervertebral disk herniation
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Hypermobile joints
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Rheumatoid arthritis
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Inflammatory phase of ankylosing spondylitis
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Psoriatic arthritis
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Reiter syndrome
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Anticoagulant therapy
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Congenital bleeding disorder
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Acquired bleeding disorder
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Inadequate physical and spinal examination
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Poor manipulative skills
Absolute Contraindications
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Active inflammatory arthropathy
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Acute spondyloarthropathy
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Demineralization
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Ligamentous laxity with subluxation/dislocation
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Tumor/metastasis
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Spinal infection/osteomyelitis
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Acute fracture/dislocation
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Severe osteoporosis
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Acute myelopathy
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Cauda equina syndrome
Relative Contraindications
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Severe spondylosis
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Known malignancy
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Benign bone tumor
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Spinal trauma
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Spinal hypermobility
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Acute disk herniation
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Ankylosing spondylitis/spondyloarthropathy
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History of spinal surgery
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Acute soft tissue injury
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Blood dyscrasia
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Anticoagulation
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History/symptoms of vertebrobasilar insufficiency
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Bone demineralization/osteopenia
Additional Treatments/OMM Techniques
Muscle Energy is a technique that utilizes the patient’s active participation to voluntarily move a muscle and restore range of motion beyond a diagnosed barrier. This technique has been used extensively by therapists and is often referred to as contract-relax technique or Proprioceptive Neuromuscular Facilitation. The patient is positioned into the barrier (restricted range of motion component) and is asked to contract away from the barrier against an isometric, holding force. The muscle contraction is held for 3–5 s. Then there is a period of postisometric relaxation, during which the new barrier (with increased ROM) is passively reengaged. This is repeated until no further incremental improvements are achieved.
Myofascial Release is a technique founded on the premise that the body is encased in fascia, a type of connective tissue that interconnects all bones, muscles, nerves, and internal structures. Because of this interconnectivity, injury in one area can result in pain and dysfunction at a distant point. Direct myofascial technique involves loading the myofascial tissues, holding the tissues in position, and waiting for release. The release is perceived by the practitioner treating the patient. This results in increased range of motion and reduced pain symptoms.
Massage is a general technique of soft tissue manipulation with the goal of producing beneficial effects on the nervous and muscular systems as well as optimizing circulatory flow of both blood and lymph. There are multiple techniques which are typically categorized based on geographic region of origin.
Western techniques—“Swedish massage”
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Effleurage—gliding of hands/fingers over the skin in a rhythmic, circular pattern with varying degrees of pressure ( Fig.14.2 ).
Fig. 14.2
Effleurage massage. This type of massage being performed on the patient’s posterior shoulder is a rhythmic, circular motion with the fingertips. Pressure can be varied to massage deeper structures.
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Petrissage—kneading motion involving compression of skin between the thumb and fingers, typically by alternating hands in a rhythmic, rolling motion ( Fig. 14.3 ).
Fig. 14.3
Pétrissage massage: “rolling.” In this form of pétrissage, the skin or muscle is gathered up between the fingers and thumb and rolled continuously, gathering new skin and muscle.
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Tapotement—percussion massage—includes hacking, clapping, beating, pounding, and vibration ( Figs. 14.4 and 14.5 ).
Fig. 14.4
Tapotement massage: “hacking.” Hacking involves striking the body at right angles with the ulnar aspect of the hands.
Fig. 14.5
Tapotement massage: “cupping.” Cupping is frequently performed over the rib cage to loosen secretions in the lungs.
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Friction—small surface area pressure performed in a circular, longitudinal, or transverse motion with the goal of breaking down adhesions/scar tissue, loosening ligaments, and disabling trigger points ( Fig. 14.6 ).
Fig. 14.6
Friction massage. Friction massage being performed on the lateral epicondyle to promote tendon healing.
Eastern techniques
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Acupressure
Acupressure is similar to acupuncture in terms of its analysis of the human body, but it uses pressure rather than needles to achieve its effects. There are benefits including the elimination of potential complications of bleeding and infection and expands the range of patients who might benefit from this treatment to include individuals receiving anticoagulants, those with needle phobia, and those who are severely immunosuppressed. Acupressure can also be taught to the patient who can then apply this technique as self-treatment on a more frequent basis. This can be very helpful in the early stages of treatment when the duration of the relief from acupressure may be short-lived.
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Reflexology
Reflexology is a healing art based on the theory that there are reflexes in the feet and hands that correspond to every part of the body. The theory behind the treatment is that the entire body has been comprehensively mapped on the hands and feet, similar to topographic mapping of the brain. Pressure can be applied to specific parts of the hands and feet to influence the parts of the body being treated. At this time, evidence of its benefit in the treatment of any particular condition is limited.
Rolfing
A therapy technique similar to massage based on “structural integration.” The goal of treatment is to achieve proper vertical alignment and efficient movement. A typical regimen involves superficial massage with progression to deeper friction massage in an attempt to stretch fascia and allow muscles to relax and lengthen. Preliminary clinical studies with small samples of patients with chronic musculoskeletal pain and chronic fatigue syndrome suggest positive effects on gait, pain reduction, improved ROM, functional status, and subjective well-being.
Traction
Traction is a technique used to stretch soft tissues with the goal of separating joint surfaces by the use of pulling force. The forces can be delivered by various methods, including manual, mechanical, motorized, hydraulic, or with the assistance of gravity. Duration of force can range from continuous (long duration), sustained, or intermittent (cycled, short duration). In order for the treatment to be effective, the surface resistance of the targeted area must be overcome. The physiologic effects of traction have been extensively evaluated and reported. Traction can stretch muscles and ligaments, tighten the posterior longitudinal ligament to exert a centripetal force on the annulus fibrosis, enlarge the intervertebral space and intervertebral foramina, and separate apophyseal joints. Specific types of traction are demonstrated below for both cervical ( Fig. 14.7 ) and lumbar spine ( Fig. 14.8 ) ( Table 14.2 ).
