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PrintTreatment Options for Chronic Pain- What Does the Research say?
As discussed in the previous article, chronic pain can manifest through very complex thought processes, as result of a wide variety of factors stemming from physical, psychological and cultural influences.
For this reason, there is not one single fix for chronic pain, but its treatment is very much defendant on a combined approach.
This article will focus on the conservative management of chronic back pain whilst not negating the importance of appropriate pharmaceutical and other interventions.
So what does the research say?
- Exercise therapy -the first line treatment
The current evidence suggests exercise is more effective than “GP care” for the reduction of pain, disability and return to work . No one form of exercise (e.g. Aerobic, Mckenzie, conditioning exercise) appears to be superior to the other, although an supervised and individualised exercise programme is recommended over general exercise conducted individually. This is something that can be discussed and provided by a qualified physiotherapist following a thorough assessment of your back.
Studies comparing the effect of pilates based exercises and usual back care, has shown pilates to significantly reduce low back symptoms and disability over long term basis.
There is strong evidence showing that exercise therapy alone is not more effective than conventional physiotherapeutic techniques (e.g joint mobilisations) and therefore exercise therapy must be prescribed along side other treatment adjuncts.
- Cognitive behavioral therapy
This form of psychosocial therapy assumes that maladaptive, or faulty, thinking patterns cause maladaptive behavior and “negative” emotions (Maladaptive behavior is behavior that is counter – productive or interferes with everyday living).This treatment focuses on changing an individual's thoughts (cognitive patterns) in order to change his or her behavior and emotional state, allowing them to partake in exercise and all activities of daily living.
- Manual therapy
Joint mobilizations should be considered as treatment in the short term management for chronic pain sufferers to increase function and decrease pain.
The research shows that joint mobilizations carried out in physiotherapy treatments is of equal effectiveness to analgesia, normal "GP care" and physiotherapy exercises in reducing symptoms.
- Massage
Massage is not considered as an effective treatment option for chronic pain sufferers, but may be useful to treat the symptoms of muscle tightness post exercise.
- Education
This is vital in in helping people understand that beliefs can alter and affect their recovery from pain. Pain should not been taken for granted, and a person should seek medical advice to decrease the amount of pain as soon as possible.
Education regarding pain, and understanding that pain is an unpleasant but subjective emotional experience, and therefore should not be used as a tool to measure the amount of tissue damage is vital.
Having less fear and anxiety will make a person more willing to return to functional activities and exercise allowing for recovery.
References:
O. Airaksinen, J. I. Brox, C. Cedraschi, J. Hildebrandt, J. Klaber-Moffett, F. Kovacs, A. F. Mannion, S. Reis, J. B. Staal and H. Ursin, et al (2006) European guidelines for the management of chronic nonspecific low back pain, European spine journal, vol 15: 193-300
Rydeard,R., Legar, A., Smith, D (2006) Pilates-based therapeutic exercise: effect on subjects with nonspecific chronic low back pain and functional disability : A randomized controlled trial, The Journal of orthopaedic and sports physical therapy, vol 36:474-484
Understanding Shoulder Injuries sustained from Sports (Video)
Do you play sports that involve alot of shoulder movements? Or have suffered shoulder pain before? If yes, then click the following.
Hav
Taping for Shin Splint
Are you experiencing Shin Splint frequently and desperate to relief the pain so that you can continue your sports? Click on the following link to find out more about an effective taping method for temporary relief.
Is the Outcome of ACL Surgery really better than Conservative Management?
If you have sustained an ACL ( Anterior Cruciate Ligament of the knee) tear and is considering an ACL surgery, you would find it useful to know more about the latest research discussion on ACL surgery versus Physical therapy management.
Knock Knees – Can I reverse it? (Part 2)
In the previous entry for Knock Knees, we discuss about the different types of knock knees and the contributing factors of it. Now, we will talk about the problems of this condition and ways we could get rid of it.
The Problems of this condition
The alignment of the knee joint in someone with knock knees is such that there is an increased force on the medial (inner) part of the knee joint. This can predispose the knee joint to osteoarthritis because of the increased loading on the medial compartment.
Symptoms from this may not even present within the knee joint, you may have ankle problems or hip problems as a result of having knock knees.
How do I get rid of it?
External aids:
1. Orthotics
The knee joint may appear to be misaligned if the foot is not biomechanically sound. This means that someone with a very pronated/inverted/flat feet may be at risk of developing a symptoms similar to someone with knock knees. Placing an insole or orthotics device may help correct the foot position, and indirectly the alignment of the knee joint.
2. Knee braces
These can help prompt correct alignment of the knee joint, but may create a degree of dependency.
3. Strengthening
A physiotherapist can design an exercise program to help strengthen weak muscles. By focussing on the specific muscles that require strengthening, you will put your body is a safe healthy direction, and will be able to train for all types of sporting challenges and limit your risk of injury.
4. Stretching
Stretching is an important component of knock knee reversal. When a joint has spent all it’s time in a misaligned position, certain structures will shorten and become stiff. Stiffness in the joints and muscles will make it very difficult to train and strengthen the area. A physiotherapist can assess the position of your knee, ascertain which structures are tight, and give you an appropriate stretching program.
Maybe it’s not Plantarfasciitis but Heel Fat Pad Syndrome
Do you have heel pain? And think it is Plantar Fasciitis?
Maybe not, it might be another type of heel pain called the Heel Fat Pad Syndrome.
What´s the difference between the Plantar Fasciitis and Heel Fat Pad Syndrome?
As shown in the illustration, both structures are in the same area of the heel whereas the plantar fascia (illustrated as plantar apponeurosis) is covered by the fat pad. The plantar fascia attaches at the toes and forms the medial (longitudinal) arch of the foot. It provides static support of the medial arch and dynamic shock absorption. The main functions of the fad pad is shock absorption of stress during heel strike (heel contact during walking).
While both the heel fat pad and plantar fascia can be a source for heel pain, the contributing factors, clinical signs and symptoms and management for them differ.
Plantar Fasciitis
Plantar fasciitis is an overuse condition of the plantar fascia.
Contributing factors: It is often seen in people with foot deformities e.g. flat feet (low arches) or pes cavus (high arches). This deformities can lead to an excessive strain at the fascia during walking and hence cause pain. Other risk factors which can lead to increased stress in the fascia are inappropriate or non-supportive footwear, reduced ankle mobility, obesity and work related weight bearing.
Clinical signs and symptoms: A typical clinical sign is swelling of the plantar fascia and can be confirmed by ultrasound investigations. People with plantar fasciitis classically have a gradual onset of symptoms and feel their pain more on the inner side of the heel. Further symptoms are acute tenderness of the inner side of the heel, a tight plantar fascia and pain during stretching of the fascia. Especially the first steps in the morning or after rest are painful. The pain seems to decrease after a few minutes, and returns as the day proceeds and time on the feet increases.
Management: Due to the tightness of the plantar fascia that leads to pain, treatments involve stretching and massaging to release the tight fascia and calf muscles. Other management include avoiding aggravating activities (e.g. wearing heels), cold therapy (R.I.C.E), anti-inflammatory drugs, taping to to relief pain and lastly it is crucial to strengthen calf muscles that have weakened during the pain process. Some patients who are still symptomatic after conservative treatment might need surgery.
Heel Fat Pad Syndrome
Heel fat pad syndrome is often caused by a decreased elasticity of the fat pad. A fall onto the heel from a height or chronically excessive heel strike with poor footwear can also lead to heel pain.
Contributing factors: Increased age and weight decreases the elasticity of the fat pad.
Clinical signs and symptoms: Compared to plantar fascitis, fat pad related heel pain is felt more at the outer side of the heel especially when the heel gets loaded (heel strike). MRI investigations will reveal changes in the fat pad showing signs of swelling.
Management: Treatments aimed at unloading the heel by avoiding aggravating activities. In an acute situation the R.I.C.E. rule (Rest Ice Compression Elevation) should be applied and anti inflammatory drugs are given. Further treatment includes taping, the use of a silicone gel heel pad and use of appropriate footwear.
References:
- Brukner, P & Khan, K 2007, Clinical Sports Medicine, 3rd edition, Tata McGraw Hill, Australia .
Management for ITB friction syndrome
Heat or Ice? When to use which?
When should you use heat or ice therapy? The answer is – it depends. In general, heat therapy is for chronic conditions and ice is useful in acute situations.
If you recently sustained an injury or aggravated an old injury, ice should be applied for a period of 15mins each time for the first 3 days. If you feel your muscles are feeling tight and stiff, a hot pack on the muscles will help to relieve the tightness.
This spectrum of acute to chronic looks at the duration since injury. If the injury is sustained within 36 hours, it is considered to be in the acute stage. At this stage the inflammation process is ongoing. Ice will help to bring down the inflammation and swelling so that the injury can heal better. Note that applying heat to this stage will increase the blood circulation, inflammation and hence swelling.
There are 2 common scenarios that cause pain, making you reach for that heat/ice pack. One of them is the acute injury (for example a fall, twisting movement or direct blow that is immediately painful) and the other is the chronic injury (happened over a period of time or from an acute injury that failed to heal). Each scenario requires a different approach to reducing your pain and speeding up your recovery.
Acute Injuries
It might be that you have just sprained your ankle playing soccer, shut your fingers in the car door or fractured your hand. All these are examples of acute injuries and will show the following signs:
- Sharp, severe pain
- Swelling
- Redness
- Increased warmth
- Restricted joint movement
- Unable to put weight through the structure (e.g. leg, ankle, wrist etc).
Flickr: Kyle May
There are many ways of applying ice like using an ice pack; wrapping ice cubes in a wet towel or using a bag of frozen peas (sometimes that is the only thing on hand!). The cold agent should be in contact with the area for up to 20 minutes at a time and re-applied every 2-3 hours for around 3-5 days or until the swelling settles.
How does ice work?
1. Decreasing the pain
There are a few proposed theories regarding how ice decreases pain and it is possible that a combination of some of them can cause pain relief.
- Decreased nerve transmission in pain fibres
- Cold reduces the activity of free nerve endings
- Cold raises the pain threshold
- Cold causes a release in endorphins
- Cold sensations over-ride the pain sensations
2. Reducing swelling
Ice cools the surface of the skin and its underlying tissues, causing narrowing of the blood vessels. This narrowing leads to a decrease in the amount of blood delivered to the area and subsequently reduces the amount of swelling. After a few minutes, the blood vessels re-open allowing blood to return to the area. The narrowing and opening repeat in cycles.
The decrease in swelling also allows more movement in the area and lessens the loss of function associated with the injury. Pain is also reduced as pressure from the swelling lessens. Chemicals that intensify the pain are released into the bloodstream when tissues are injured, thus the narrowing of the vessels help to minimize this release and pain.
3. Decreasing metabolic rate
Ice reduces the metabolic rate and oxygen requirements of the cells. Thus, even with the decreased blood flow and oxygen delivery that comes with narrowing of the vessels, the risk of cell death will be lessened. This prevents further injury.
Sub-acute phase
A few days following an acute injury, the pain and swelling may have decreased so much that there may be no sign of the original injury. However, the tissues are still in the process of recovery and will still benefit from modifying your activities (less vigorous) as well as using both ice and heat alternatively. This means to apply ice for 10 minutes, followed immediately by 10 minutes of heat.
How does this work?
Doing this will cause massive increases in blood flow to the area as the narrowing caused by cooling is reversed when heat is applied, resulting in an influx of blood to the damaged tissues. The increased blood flow to the area provides proteins, nutrients and oxygen for better healing. It also helps remove the products of inflammation and reduce residual swelling.
An important point to note is to ensure that inflammation has stopped before applying this technique. That means that the area should not be red, and should not be warm to touch.
Chronic Injuries
Flickr: Capture Queen
In order to treat these, heat should be used to help relax tight, aching muscles and joints, increase the extensibility of ligaments and tendons and promote blood flow to the area. Heat can also be used before exercise in chronic injuries to warm the muscles and increase flexibility.
Heat can be applied to the area in the form of heat packs, a warm damp towel, hot water bottles or heat rubs. If using a heat pack or hot water bottle, ensure a suitable layer of protection is placed over the skin to prevent burns. The heat should be applied for 15-20 minutes.
How does heat work?
Heat applied on the skin increases the temperature of the skin and the underlying tissues. This in turn opens up the blood vessels like your ateries, allowing more blood to flow into the area. This increase flow helps to remove waste products from cells and deliver more nutrients, relaxing tissues. The increased temperature of the blood also warms up surrounding tissues. Heat also has an effect of increasing flexibility of the soft tissues.
Both heat and ice are cheap, easy to use and effective ways of speeding up recovery when used correctly. Besides managing your injuries with these modalities, it may be a good idea to consult a physiotherapist in helping you rehabilitate and/or prevent the same injuries from occurring.
Ladies! Stronger Thighs, Lesser Knee Pain
Knee pain is one of the most common, if not the most common complain of pain in the elderly. In the USA, nearly 4 million sufferers of knee pain above the age of 45 are ladies.
Why are females more prone?
There are quite a number of reasons why ladies are more pre-disposed to developing knee pain. The reasons range from wider hips to increased Q-angle, tighter ilio-tibial band (ITB) to weaker physique. However, what is the most common cause of knee pain? The answer lies in the weakness of the quadriceps or thigh muscles. (more…)
What can i do for a hamstring “pull”
Pulling one’s hamstring is one of the most common soccer injuries and the most common cause is the lack of proper stretching before playing. When one says that they pull their hamstring, what it means is that one has strained or slightly torn their hamstring. Most soccer players think that by just resting for about 2-4 weeks without playing is all that is required to recover. However, this is not true. If you do nothing about the strain, you are at a higher risk of sustaining the same injury.
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