Treatment of pain and inflammation aims to facilitate movement and improve coordination of muscles and joints. Nondrug treatments include therapeutic exercise, heat, cold, electrical stimulation, cervical traction, massage, and acupuncture. These treatments are used for many disorders of muscles, tendons, and ligaments (see Table: Indications for Nondrug Pain Treatments). Prescribers should include the following:
Indications for Nondrug Pain Treatments
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 min/day. Contraindications include any advanced heart disorder, peripheral vascular disease, impaired skin sensation (particularly to temperature and pain), and significant hepatic or renal insufficiency. 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 min. 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 finger arthritis.
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.
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, acute 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.
Cold may be applied locally using an ice bag, a cold pack, or volatile fluids (eg, ethyl chloride, vapocoolant spray), which cool by evaporation. Spread of cold on the skin depends on the thickness of the epidermis, underlying fat and muscle, water content of the tissue, and rate of blood flow. Care must be taken to avoid tissue damage and hypothermia. Cold should not be applied over poorly perfused areas.
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 min 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. Because TENS may cause arrhythmia, it is contraindicated in patients with any advanced heart disorder or a pacemaker. It should not be applied over the eyes.
Cervical traction is often indicated for chronic neck pain due to cervical spondylosis, disk prolapse, whiplash injuries, or torticollis. Vertical traction (with patients in a sitting position) is more effective than horizontal traction (with patients lying in bed). Motorized intermittent rhythmic traction with 7.5 to 10 kg is most effective. For best results, traction should be applied with the patient’s neck flexed 15 to 20°. 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.
Massage may mobilize contracted tissues, relieve pain, and reduce swelling and induration associated with trauma (eg, fracture, joint injury, sprain, strain, bruise, peripheral nerve injury). Massage should be considered for low back pain, arthritis, periarthritis, bursitis, neuritis, fibromyalgia, hemiplegia, paraplegia, quadriplegia, multiple sclerosis, cerebral palsy, certain types of cancer, and amputation. Massage should not be used to treat infections or thrombophlebitis. It is not advised for patients with severe allergies because it causes histamine to be released throughout the body. Only a licensed or certified massage therapist should use massage for treatment of an injury because of variability in therapists’ training and skills.
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.