Rehabilitative Measures for Treatment of Pain and Inflammation

Heat provides temporary relief in subacute and chronic traumatic and inflammatory disorders (eg, sprains, strains, fibrositis, tenosynovitis, muscle spasm, myositis, back pain, whiplash injuries, various forms of arthritis, arthralgia, neuralgia). Heat increases blood flow and the extensibility of connective tissue; heat also decreases joint stiffness, pain, and muscle spasm and helps relieve inflammation, edema, and exudates. Heat application may be superficial (infrared heat, hot packs, paraffin bath, hydrotherapy) or deep (ultrasound). Intensity and duration of the physiologic effects depend mainly on tissue temperature, rate of temperature elevation, and area treated.

Infrared heat is applied with a heat lamp, usually for 20 minutes/day. Contraindications include implanted metal device and impaired skin sensation (particularly to temperature and pain). Precautions must be taken to avoid burns.

Hot packs are cotton cloth containers filled with silicate gel; they are boiled in water or warmed in a microwave oven, then applied to the skin. The packs must not be too hot. Wrapping the packs in several layers of towels helps protect the skin from burns. Contraindications are the same as those for infrared heat.

For a paraffin bath, the affected area is dipped in, immersed in, or painted with melted wax that has been heated to 49° C. The heat can be retained by wrapping the affected area with towels for 20 minutes. Paraffin is usually applied to small joints—typically, by dipping or immersion for a hand and by painting for a knee or an elbow. Paraffin should not be applied to open wounds or used on patients allergic to it. A paraffin bath is particularly useful for hand osteoarthritis.

Hydrotherapy may be used to enhance wound healing. Agitated warm water stimulates blood flow and debrides burns and wounds. This treatment is often given in a Hubbard tank (a large industrial whirlpool) with water heated to 35.5 to 37.7° C. Total immersion in water heated to 37.7 to 40° C may also help relax muscles and relieve pain. Hydrotherapy is particularly useful with range-of-motion exercises.

Diathermy is therapeutic heating of tissues using oscillating high-frequency electromagnetic fields, either short-wave or microwave. These modalities do not seem superior to simpler forms of heating and are now seldom used.

Low-level laser therapy (also known as cold laser) applies light energy to deeper tissues and may provide analgesia for a variety of conditions, including sprains, strains, neck and back pain, shoulder pain, and fibromyalgia. It should not be used over the eyes, and appropriate safety eyewear is required. It should also not be used at the site of known malignancy, over a developing fetus, over a pacemaker or other implanted device, or over the thyroid gland. Low-level laser therapy can also trigger a seizure in patients with photosensitive epilepsy and should be used with caution in such patients. Although some evidence suggests potential benefit of low-level laser therapy for specific musculoskeletal conditions, the results are mixed depending on the specific condition being treated and the treatment comparisons.

Ultrasound uses high-frequency sound waves to penetrate deep (4 to 10 cm) into the tissue; its effects are thermal, mechanical, chemical, and biologic. It is indicated for tendinitis, bursitis, contractures, osteoarthritis, bone injuries, and complex regional pain syndrome. Ultrasound should not be applied to ischemic tissue, anesthetized areas, or areas of acute infection nor be used to treat hemorrhagic diathesis or cancer. Also, it should not be applied over the eyes, brain, spinal cord, ears, heart, reproductive organs, brachial plexus, or bones that are healing.

The choice between heat and cold therapies is often empiric. When heat does not work, cold is applied. However, for acute injury or pain, cold seems to be better than heat. Cold may help relieve muscle spasm, myofascial or traumatic pain, low back pain, and acute inflammation; cold may also help induce some local anesthesia. Cold is usually used during the first few hours or the day after an injury; consequently, it is seldom used in physical therapy.

Transcutaneous electrical nerve stimulation (TENS) uses low current at low-frequency oscillation to relieve pain. Patients feel a gentle tingling sensation without increased muscle tension. Depending on the severity of pain, 20 minutes to a few hours of stimulation may be applied several times daily. Often, patients are taught to use the TENS device and decide when to apply treatment. TENS therapy should not be applied over or close to the area where an electronic device is implanted, because TENS could cause such a device to malfunction. It should not be applied over the eyes.

Cervical traction is often indicated for chronic neck pain due to cervical spondylosis, cervical radiculopathy, whiplash injuries, or torticollis. Vertical traction (with patients in a sitting position) is more effective than horizontal traction (with patients lying in bed). For both motorized intermittent rhythmic traction and static traction, the amount of weight used varies, but generally should provide a gentle stretch to the neck muscles but not cause pain. Generally, hyperextension of the neck should be avoided because it may increase nerve root compression in the intervertebral foramina. Traction is usually combined with other physical therapy, including exercises and manual stretching. Traction is generally avoided in patients with longstanding rheumatoid arthritis or other inflammatory arthropathies involving the cervical spine.

Massage may mobilize contracted tissues, relieve pain, and reduce swelling and induration associated with trauma (eg, fracture, joint injury, sprain, strain, bruise). Massage should be considered for low back pain, fibromyalgia, hemiplegia, myofascial pain, cerebral palsy, and amputation. Massage should not be used to treat infections or thrombophlebitis. Only a licensed or certified massage therapist should use massage for treatment of an injury because of variability in therapists’ training and skills.

In acupuncture, thin needles are inserted through the skin at specific body sites, frequently far from the site of pain. Acupuncture is sometimes used with other treatments to manage acute and chronic pain.