When it Hurts to Move, and you just want the Pain gone…You have Options!
Pain is the main reason why our clients seek care; and I expect this runs true for clinics throughout St John’s, Mount Pearl and all the communities of Conception Bay South and throughout the Avalon environs. Whether back or neck pain, arthritis, tendonitis, bursitis, or trauma like a whiplash injury, etc, our clients can access care through physiotherapy, massage therapy, acupuncture and laser. All of these therapies offer modalities for pain relief, but our experience indicates that collaboration between the therapies offers the best and longest lasting pain relief. But, as manager of your own health, you have options.
Pain follows injury and trauma; it is a protective mechanism initiated by the brain to prevent worsening damage, and it is part of the healing response. Pain may also be complex, triggered by multiple threats, such as large or multiple sites of trauma, stress, possibly NSAID use and poor alignment. Whether simple or complex, the modalities we can offer at our clinic are the same for both simple and complex pain, although the manner of application may change depending upon the nature of pain. The purpose of this blog is to familiarize you with how our modalities actually relieve pain; offer some useful hints for managing pain at home; review the common medications and their impact on therapy; and to explain why we believe a collaborative approach to managing pain provides the best outcomes.
Acupuncture is both the name of the health profession and the main modality the profession provides. By inserting very fine needles into ‘acupoints’ located along energy meridians, it is speculated that acupuncture rebalances energy flow throughout the body. Pain is relieved because it stimulates the release of endorphins, the body’s natural pain-relieving chemicals. One well-known endorphin that is stimulated by acupuncture is serotonin, a brain chemical known to be involved with mood; and which can relieve anxiety. Our experience is that pain relief is improved when a client is anxious, and acupuncture is part of their treatment plan.
There is some risk associated with poor needle technique, not a problem we’ve seen at our clinic; and symptoms such as fatigue, soreness, bruising, and light-headedness are rare and generally short-lived findings following treatment.
Massage Therapy is a hands-on and mostly well-loved experience of manual stimulation of muscles, joints and soft tissues. There are believed to be several reasons why massage may relieve pain, including relaxation of painful muscles, tendons and joints; improving local circulation and the supply of nutrients to the painful area; and by soothing the joint nerve receptors which transmit the information of pain to the brain. All together, an important effect of massage therapy is to stimulate parasympathetic function, the body’s rest and digest mode. This diminishes stress and promotes self-repair. Relief following massage is reported to be short-lived. A deep massage may increase pain for a couple of days immediately following massage; with subsequent relief lasting for 2 to 3 days. Our experience is that pain relief is improved when massage is combined with other therapies.
Massage techniques range from the mild lymph massage to the moderate Swedish massage to the intense deep muscle massage. There are also special techniques for specific client populations, such as pregnancy massage. Trigger point release is an example of a deep tissue technique which is often required for those with muscle and joint pain.
Because massage is used for relaxation and stress relief as well as for re-aligning and restoring muscle tension, the recommendations for frequency and duration are variable.
Physiotherapy offers a wide range of electrotherapeutic modalities and manual techniques specifically for pain relief. The main electrotherapeutic modalities in common practice today include:
- Ultrasound, low energy sound waves
- Extracorporeal shock wave therapy, high energy sound waves
- Interferential current
- Electrical stimulation and TENS
- Non-electrical modalities include heat and cold.
The risks of treating with heat and cold are mainly of burns and frost-bite.
With respect to the other electrical modalities, except laser, risks are quite varied.
Ultrasound left in one spot can cause a cavitation burn (damage deep before there’s evidence of burn on the surface). Interesting that Extracorporeal shock wave therapy uses the cavitation effect to treat calcifications in tissues like tennis elbow. Interferential current and other electrical currents can interrupt cardiac rhythm, especially if a client is dependent on a pacemaker. There are other more common cautions and contra-indications which are not listed because we don’t use these modalities in our clinic.
The best of the modalities that physiotherapy uses for pain relief is actually motion itself. The use of thermal and some electrical modalities were originally used to manage the pain and swelling associated with early trauma. They were intended to ease and support early movement, starting with gentle muscle contraction without motion and progressing to motion within pain-free and normally aligned range and on to more challenging exercise. The risks of early exercise are poor alignment, too much/too little effort, and delayed healing. Sometimes, the modalities steal focus from early movement and all the neurological benefits early movement provides.
Beyond the early exercise mentioned above, it is key that synergy between muscle fibers within a muscle and the nerves which transmit information to the brain be restored to normal function. This is often referred to as retraining the brain or the mind/muscle memory; and it is essential when using movement for successful pain relief. It is like hitting reset on the computer to clear a software glitch. Such exercise is first performed with minimal effort and for longer durations than is typical of regular exercise. You may think…wait, Yoga or Pilates does that; and it does. They are great exercise systems when the neural ‘software glitch’ is minimal; but they can’t generally restore a more entrenched ‘glitch’.
Laser Therapy, specifically low intensity laser,is also an electrical modality, but in a class by itself. All other electrical modalities either influence circulation and the supply of hormones and nutrients; or, stimulate larger sensory neurons to block transmission of pain fibers. Laser, properly termed photobiomodulation, replicates the healing rays of red and infrared energy; and directly delivers ATP (cell fuel) to injured cells to directly stimulate cell function. It is analogous to photosynthesis, the mechanism by which plants grow. Laser is reported to restore normal cell function and structure. It has one contra-indication; and that is not to treat the exposed eye. Neither do we treat over the pregnant womb nor over a known cancer. If any modality, alone, could provide total pain relief, it would be laser…. But that would be assuming normal function before injury; and that’s rare.
Pain Medications & NSAIDS
It is more common than not for our clients to try non-prescription meds as a first line of treatment when it hurts to move. Once clients seek help from their physicians, some will move on to prescribed medications. From the perspective of our therapists, it is important to know what medications are being taken, and whether or not they are effective in relieving pain. Also, because there may come a time when it is important to distinguish between the medication effect and true recovery, sharing knowledge of medication usage is important.
Perhaps the most common medication our clients report taking is Tylenol, acetaminophen, a drug used to reduce fever and relieve minor pain. It is thought to work by elevating the body’s overall pain threshold. It has many side effects, many of which are allergenic.
NSAIDs are a group of drugs, used to block prostaglandin effects during the inflammatory process. They include Aspirin, Ibuprofen, Aleve, Motrin, Naprosyn and Celebrex, etc. While it seems intuitive that it is good to block that which causes pain, the inflammatory process is also the body’s repair process, and the prostaglandins, in addition to sensitizing nerve endings and increasing the pain, serve an important function in regulating this process. The published literature is mixed on the use of NSAIDs for muscle and bone injuries. In some reports, it is considered a possible cause in delayed healing. One alternative is the use of topical NSAIDS, in cream or gel form. It is reported to relieve pain, without adverse systemic effects, especially for knee osteoarthritis.
Many of our clients receive corticosteroid (cortisone + a steroid + an analgesic) shots for joint pain when medications and other more conservative measures don’t provide sufficient pain relief. The purpose is to dampen the inflammatory response. The Mayo Clinic reports that side effects could include: cartilage damage, thinning or death of nearby bone, joint infection, nerve damage, tendon weakening or rupture, etc.
Although there appears to be no widespread consensus regarding the frequency of shots a person can have, it is common for physicians to limit the number of cortisone shots into a joint. For more specific advice, let your own physician be your guide. For our part, we will treat clients who’ve recently had or who are awaiting corticosteroid injections. It is only important that we know that you’ve had such an injection and the date; this allows us to better gauge your progress, and modify if necessary your treatment plan.
For complete information on medications and possible side effects and interactions, it is best you consult your pharmacist or physician to determine what’s best for you.
Home Strategies. There’s quite a bit you can do to manage pain at home and to extend the benefit derived from in-clinic treatment. Beyond medications, there is pain relief to be found in good positioning; in ice and elevation following recent injury; and in movement. The following ‘exercises’ are amongst the most commonly included in the home exercise programs we provide:
1) Static Back Position. The purpose of this ‘exercise’ is to allow back muscles to relax such that the back can assume a more normal alignment. It is important that hips and knees are supported at right angles, as this negates rotational strain on the back.
2) Towel Wrap around Neck. This ‘exercise’ supports the neck muscles, essentially taking some of the weight of the head off the neck. It is particularly useful following sprain/strain injuries, such as whiplash; but we use it for muscle spasm as well. Leave the neck wrapped for 2 hours or so, at a time. We don’t recommend continual use, but the ‘exercise’ can be repeated as needed. Our favorite towels for this application are worn, fairly skinny towels. They wrap in closer to the neck and are more supportive. Either tie with a scarf or tape to secure. To further relieve your neck muscles, support your forearms on blocks, or cushions, close to your body; and with shoulders held in a relaxed, neutral position.
3) Side Sleeping. The important things here are that pillow support under your neck and between your legs is just enough to maintain a straight spine, as viewed from behind (as in picture). What you can’t see, but which is important, is that the support is sufficient to discourage rotation; as when the top knee falls forward of the bottom knee and/or the top shoulder slides forward of the bottom shoulder.
4) Resting Positions of Joints. This is the position in which there is the greatest laxity of the joint capsule, and where recovery will be the most comfortable. For the knee joint, it is slightly bent and supported by pillows. For any joint, consult Dr Google.
The Collaborative Approach Not everyone needs a coordinated, collaborative approach to care; we offer both single service and collaborative care plans. We do recommend the collaborative approach for those:
- with recurring pain from earlier injury,
- with serious and/or multi-site trauma, and
- those for whom stress or anxiety may contribute to their pain experience.
Collaborative care requires discussion between care providers to compare findings and define a care plan; and it provides opportunities to extend insurance benefits by combining and/or spacing treatments. All care is provided within the same facility, which enables easy discussion between practitioners and offers convenience for our clients.