Immersion in hot and cold water alternatively creates an alternating mechanical force. The procedure involves immersing the affected limb, 3–7 times, alternatively in a hot bath for 2–3 min followed by a cold bath with ice and water for 1–2 min. The methodology is not standardized and protocols may vary by temperature range, timing, and overall duration. Cold water temperatures can vary from 45 to 71.6°F and warm/hot water temperatures range from 80 to 113°F. Contrast baths are used to decrease edema, stiffness and pain in patients with rheumatoid arthritis, diabetes, foot or ankle injuries. Hand therapists may use contrast baths before and after surgery to reduce hand volume, alleviate pain, and decrease stiffness in affected limb. The benefit of contrast bath has been poorly substantiated and a systematic review failed to find evidence to support its use (Breger Stanton et al. 2009). A randomized controlled study demonstrated that contrast bath treatments, pre- and/or postoperatively, in Carpal Tunnel Syndrome patients had no significant effect on increase or decrease of hand volume (Janssen et al. 2009).

Heat wraps are disposable cloth like patches that heat up to 104°F within 30 min on exposure to air and last for at least 8 h. Continuous low level heat wrap therapy has been employed in treatment of acute low back pain alone or in combination with exercises in three large randomized control trials (Nadler et al. 2003a, b; Mayer et al. 2005). Heat wrap therapy resulted in greater pain relief, less muscle stiffness, increased flexibility and functional improvement with decreased disability in comparison with placebo, or control interventions. One study reported sustained positive effects of treatment 48 h later. No study has described utility of heat wraps in chronic pain. In patients with chronic pain, this modality may help manage an acute exacerbation of pain or pain flares.

Ultrasound (US) is a commonly used modality in the treatment of soft tissue injury and musculoskeletal pain. Therapeutic ultrasound involves application of high frequency acoustic energy to produce thermal and mechanical effects in tissues. Phonophoresis is use of ultrasound energy in combination with an analgesic or anti-inflammatory medication. As yet the clinical effects of this method of treatment are uncertain. The value of ultrasound in chronic pain has also been questioned. A randomized control study of 221 patients with shoulder pain demonstrated that ultrasound was not superior to placebo in short-term management of shoulder pain (Ainsworth et al. 2007). Two other randomized control studies on patients with periarticular soft tissue disorder and subacromial bursitis found no significant differences between sham and true ultrasound groups for improvements in pain, ROM, and function (Downing and Weinstein 1986; Kurtais Gursel et al. 2004).

A large number of electrotherapeutic modalities are available for treating pain. Their use varies widely and is based on clinical experience or anecdotal evidence rather than actual scientific evidence. Some of the modalities have an important role to play in treating pain, but should not be used in isolation. These modalities are combined with other therapies to improve outcomes. For example, application of hot packs combined with short wave diathermy, or transcutaneous electrical nerve stimulation (TENS) prior to isokinetic exercises has been shown to augment exercise performance, reduce pain and improve function in patients with osteoarthritis of the knee joints (Cetin et al. 2008).

Traction is used in treatment of spinal pain. It involves intermittent or sustained pressure in a direction to distract vertebral bodies, or facet joints, widen (open) intervertebral foramen, and stretch spinal muscles. Traction may be manual or delivered by a traction apparatus, either with weights or an electric machine. In patients with neck pain, addition of mechanical cervical traction to a multimodal treatment program of manual therapy and exercise did not yield any significant additional benefit with respect to improvements in pain, function, or disability in cervical radiculopathy patients (Young et al. 2009). A randomized single blind study in low back pain patients compared lumbar traction to sham traction and found that low back pain scores, Oswestry disability scores, and SF-36 scores improved significantly in both groups at 14 weeks follow-up. The addition of intermittent mechanical lumbar traction (Accu-SPINA) to a standard graded activity program was of no added benefit (Schimmel et al. 2009).

Bracing with splints or orthotics is used to support or reorient moving body parts (joints, tendons), control or guide direction of movement, align a body part into more stable or less painful position, limit or stop excessive motion, and facilitate or correct motion. Semi-rigid cervical collars have been shown to decrease acute neck pain. In a randomized controlled study of 205 patients with acute cervical radiculopathy of <1 month duration, semi-hard cervical collar and rest significantly decreased pain and improved neck disability index; pain relief was comparable to that obtained by physical therapy and home exercises (Kuijper et al. 2009). In another study, significantly greater pain relief was reported by patients with patellofemoral syndrome and excessive forefoot varus or calcaneovalgus deformity, when a soft foot orthotics was added to the exercise program (Eng and Pierrynowski 1993).

Physicians who prescribe exercise therapy must understand the basics of exercise physiology and training principles and recognize that treatment must be tailored to the disease and its stage, the baseline fitness level of the patient, and the goals of the program mutually established with the patient (Kujala 2004, 2006). As a therapeutic modality, exercise has a primary goal of improving functioning of targeted tissues, that is, tissue length, tissue resilience, muscle strength, and endurance. From a cognitive standpoint, successful completion of exercise in the presence of chronic pain lessens patients’ fears and concerns, improves self-efficacy and confidence for performing daily activities, thereby decreasing disability. At the cornerstone of any rehabilitation exercise regime is the requirement that function be quantified so that progress towards this goal can be measured. For instance, in the case of chronic back pain baseline measurements of trunk and lower extremity flexibility, trunk strength, lifting capacity and cardiovascular endurance should be recorded at onset of treatment. Quantification initially serves to identify baseline impairments and guide clinicians in the selection of an appropriate level of exercise. Provided that there are no contraindications to aggressive exercise, patients are assigned to an exercise level based on measured impairments. During the initial therapy evaluation, instructions are provided regarding a home stretching program specific for measured impairments in flexibility. Stretching at the physiological limits of flexibility is performed at least twice per day. Following assessment of strength, treatment goals are established according to a patient’s age, gender, and ideal body weight (IBW). Patients are carefully instructed on the correct set-up and use of all exercise equipment. The next 1–2 weeks is dedicated towards acquiring proper exercise technique and diminishing fear of physical exertion. The second phase of treatment generally lasts between 2 and 4 weeks, during which rapid progression towards treatment goals is expected. Patients generally meet with their therapist 2–3 times/week with sessions lasting between 1 and 2.5 h. Patients who are highly motivated and experienced with exercise require only one weekly therapy session and exercise independently several more times per week. Exercise sessions involve supervised stretching, aerobic conditioning, general strengthening, specific back streng­thening, and lifting. Repeat quantification is performed every 2 weeks to monitor progress, provide feedback, and document treatment outcomes. Patients are encouraged to achieve their pre-established goals by increasing their repetitions and/or weights with each session. Exercise must provide sufficient physiologic overload to produce improvements in physical abilities. In the presence of chronic pain, this intensity of exercise will often stimulate abnormally sensitive nociceptors associated with the chronic pain symptoms and exacerbate pain complaints. These exacerbations are usually tolerable, brief and do not represent tissue damage. As training progresses, tissue function improves and the sensitivity of abnormal nociceptors tends to decrease.

Data from prospective and retrospective studies utilizing aggressive exercise as treatment for patients with CLBP reveal that within a period of 6–8 weeks, it is possible to improve trunk ­flexibility by 20%, trunk strength and lifting capacities by 50%, and endurance by 20–60%. Pain-related ­disability as determined by the Oswestry scale reduced by 50%, on average, and pain severity by 30% in one study (Cohen and Rainville 2002). Exercise is important for the prevention of osteoporosis and the reduction of fracture risk because it improves muscle mass and strength, besides improving balance. One study evaluated the effect of a specific exercise program on bone mass and quality and physical function capacity in postmenopausal women with low bone mineral density and found that the group that took part in an 11-month exercise program, consisting of a multicomponent (strength, aerobic capacity, balance, joint mobility) dual-modality (on ground and in the water; alternating group and home-based exercise periods) exercise regimen showed significantly improved femoral neck T-score as compared to the control group that did not exercise. After the training ­program osteosonography showed no differences in exercise group and significantly decreased all bone quality parameters in control group (Tolomio et al. 2010).