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10 Articles in Volume 16, Issue #4
Achilles Tendon Injuries
Brain Trauma in Sports
Genetic Testing: Adjunct in the Medical Management of Chronic Pain
Letters to the Editor: Sleep Apnea, SPG Blocks for Migraines, Pancreatic Pain, CDC Guidelines
Pain and Weather—A Cloudy Issue
Phulchand Prithvi Raj, MD, Pioneer in Pain Management, Dies at 84
Physical Medicine & Rehabilitation
Preventing Chronic Overuse Sports Injuries
Sports-Related Pain: Topical Treatments
The “Missing Link” in the Physiology of Pain: Glial Cells

Physical Medicine & Rehabilitation

A review of rehabilitative principles, modalities, and equipment needs in pain management.

Physical medicine and rehabilitation (PM&R), or physiatry, is a branch of medicine that aims to enhance and restore functional ability and quality of life to those with physical impairments or disabilities.1

Physiatrists evaluate and treat both adults and children with acute and chronic pain, including those with short- or long-term physical and/or cognitive impairments and disabilities that result from musculoskeletal conditions (neck or back pain, or sports or work injuries), neurological conditions (stroke, brain injury, or spinal cord injury) or other medical conditions (fibromyalgia). The goal of physiatrists is to decrease pain and enhance performance without surgery.2

History of PM&R

The Society of Physical Therapy Physicians was founded on September 12, 1938, during the annual meeting of the American Congress of Physical Medicine at the Palmer House in Chicago. The group elected Walter Zeiter, MD, as executive director, a position he held for 22 years. John S. Coulter, MD was elected as the first president.2

In the early years of the society, membership was limited to physicians with at least 5 years’ experience in the practice of physical therapy. According to the American Academy of Physical Medicine and Rehabilitation, “membership was by invitation only and was limited (until 1944) to 100 doctors. Dues for the newly formed organization were $5 a year, a rate that continued until 1956.” In 1939, the Society was formalized in New York and had 40 charter members.

The name of the organization continually evolved over the years. What began as the American Society of Physical Therapy Physicians in 1938 became the American Society of Physical Medicine in 1944. In 1951, the words “and Rehabilitation” were added. The present name, The American Academy of Physical Medicine and Rehabilitation, was adopted in 1955. By 1958, the group assumed the responsibility for continuing medical education (CME) for members. Today, over 8,000 physicians are members of AAPMR.

Chronic Pain Management

There are several modalities physiatrists employ to treat pain, including exercise, physical therapy, medication management, and interventional pain treatments. At times, a physiatrist may also be a member of an interdisciplinary team involving physicians, psychologists, nurses, and pharmacists when indicated.3 According to AAPMR, the goal of the PM&R specialty is to “effectively manage complex clinical, functional, and psychosocial issues associated with chronic pain management, and to restore function by minimizing pain. To that end, the society recognizes the critical balance needed in the medication management of chronic pain.2

Rehabilitation of Low Back Pain

This article will focus on treatment of low back pain. Rehabilitation, specifically for lumbar radiculopathy, occurs in 3 phases: physiatrists make a specific diagnosis, develop a treatment plan, and offer treatment options; flexibility and strength are developed to get the body parts into their proper positions; and a total body fitness program is designed to maintain body mechanics and increase endurance.

Back pain has been estimated to account for 45% of all physiatry visits and is one of the most expensive injuries to treat. The prevalence of lumbar radiculopathy is higher in men than women, occurring in 2% to 5% of men and 1% to 3% of women.4 Risk factors for low back pain include long-haul driving occupations, frequent lifting (especially with twisting), heavy industry work, back trauma, being tall, smoking, being overweight,5 having a sedentary lifestyle, multiple pregnancies in women, history of back pain, and chronic cough. Environmental factors account for most cases of sciatica, although family history of herniated disks is also a risk factor.6

During a PM&R visit, a physical exam will be performed to assess the intensity and exacerbating/alleviating factors as well as strength, reflexes, sensation, walking ability, hip range of motion, and presence of other disease symptoms. The patient’s disability may also be assessed using common questionnaires. X-rays can be used to screen for other problems, such as fractures. Magnetic resonance imaging (MRI) and CT scans are used primarily to confirm a diagnosis or in cases where rehabilitation is unhelpful. Electromyography can be used to record the electrical activity of the muscles, and diagnostic injections of medications can also be used (Table 1).4

The majority of patients (70% to 80%) experience improvement in pain and disability within 4 to 6 weeks with relative rest and activity modification, and only 1% to 10% of patients will require surgery.2 Rehabilitation management emphasizes return to activity. Heat, ice, electrical stimulation, and medications are often used. Epidural injections of steroids or surgery are used in cases where other treatments have failed. Chronic pain also can be treated with complementary and alternative modalities, such as acupuncture, massage therapy, and spinal manipulation.2

Education in body mechanics, stretching, strengthening, and aerobic exercises are among the most common treatment preferences.7 Exercise training to stabilize the trunk, as well as upper and lower body strengthening and increased flexibility, are extremely useful. Previous studies have found that a back hygiene program that included aggressive training in body mechanics increased proper movements that minimized or prevented further impairment and reduced the cost associated with back injury.8

How Do Proper Body Mechanics Affect Pain?

“Proper body mechanics” is a term used to describe the ways one moves throughout the day. It includes how one holds the body when lifting, standing/walking, driving, sitting, and sleeping (Table 2). Poor body mechanics are often the cause of back problems. When one moves incorrectly and not safely, the spine is subjected to abnormal stresses that, over time, can lead to degeneration of spinal structures like discs and joints, injury, and unnecessary wear and tear. That is why it is so important to learn about proper body mechanics.

Proper body mechanics maintain the natural curve of the spine. The spine normally curves at the neck, the torso, and the lower back area; this positions the head over the pelvis naturally. The curves also work as shock absorbers, distributing the stress that occurs during movement. When the spine curves too far inward, the condition is called swayback. Good posture means the spine is in a “neutral” position.

But what does good posture look like? You can instruct patients by using the following 5 steps:

  • Stand with the feet apart
  • Tuck the tailbone in and tilt the pelvic bone slightly forward
  • Pull the shoulders back and lift the chest
  • Lift the chin until it is on a horizontal plane
  • Relax the jaw and mouth.

Below are some additional pointers for proper body mechanics for several daily activities.9

Lifting

The process of lifting places perhaps the greatest loads on the low back and has the highest risk of injury. Use of proper lifting mechanics and posture is critical to prevent injury. Patients should be told to bend with the knees, not the back, when lifting—do not bend over with the legs straight or twist while lifting. As noted, one must lift with the legs and hold objects close to the body. When lifting objects, only lift chest-high—avoid trying to lift above the shoulder level. When a load is heavy, patients should be advised to get help, and to plan ahead to avoid sudden load shifts. It is always important that one is sure about one’s footing. In the end, it is more important how one lifts than how much the object weighs.

Standing/Walking

Millions of people spend a good deal of their time on their feet. Standing can be tough on the back, especially if proper body mechanics are not being used. One should stand with one foot up and change positions often—one should not stand in one position too long. As noted, people should be advised to stand with the back’s 3 natural curves in their normal, balanced alignment. Patients should be advised to walk with good posture, keeping the head held high, chin tucked in, and toes pointed straight ahead—do not bend forward without bending legs or walk with poor posture. Wear comfortable, low-heeled shoes—do not wear high-heeled or platform shoes when standing or walking for long periods.

Driving

According to a study by the AAA Foundation for Traffic Safety and the Urban Institute, an average American drives 29.2 miles per day, making 2 trips, with an average total duration of 46 minutes.10 That means that in a year, the average person drives 10,658 miles and in a lifetime (assuming he/she is driving at 17 and until 79 years old) around 660,796 miles.

To prevent injury while driving, one should move the car seat forward to keep knees level with the hips—advise patients not to drive far back from the steering wheel. Stretching for the pedals and wheel decreases the lower back’s curve and produces strain. Sit straight, and drive with both hands on the steering wheel. To support the lower back, one may place a lumbar support or a rolled-up towel behind the back.

Sitting

Much has been reported about Americans’ sedentary lifestyle. In fact, the more time one spends sitting (either at work, surfing the internet, or watching TV), the higher their mortality risk.11 According to the US Bureau of Labor Statistics, the average American works 7.8 hours a day and watches TV for 2.8 hours per day, which in a lifetime accounts for over
9 years’ worth of TV, or around 80,486 hours.12

Whether sitting at a desk working on a computer or on a couch watching television, it is important to keep good body mechanics in mind. To help protect the back, one must sit in a chair that is low enough to place both feet flat on the floor, with the knees level with the hips. Do not sit in a chair that is too high or too far from the desk. Avoid leaning forward and arching the back. Adjust the computer screen to eye level to avoid additional neck strain. Sit firmly against the back of the chair—do not slump. Protect the lower back with a lumbar support or rolled-up towel. Keep in mind that even sitting with good posture for long periods of time will eventually become uncomfortable. Do not forget to take breaks, get up, move around, and stretch approximately every 30 to 45 minutes. These behaviors will reduce the stress on your spine and help prevent muscle fatigue and stiffness.

Sleeping

Given that people will sleep an average of 8 hours a day, the average person will sleep for 229,961 hours in their lifetime (78.7 years), or basically one-third of their life.12 A good night’s sleep on a firm mattress is good for the back. Use a pillow that keeps the head aligned with the rest of the body. Numerous and/or oversize pillows may look great on a made bed but do not necessarily benefit the back while sleeping. Do not sleep or lounge on soft, sagging, non-supporting mattresses or cushions.

Patients should be informed about mattress flipping. After 5 to 7 years of use, a mattress may no longer provide the comfort and support needed for optimum rest.13 It is recommended to sleep on one’s side with the knees bent and a pillow between them, or on the back with a pillow under the knees. Swayback and back strain will result when sleeping on the stomach. Choose the position that feels the most comfortable.

How Does Adaptive Equipment Help With Pain?

Due to a disability or after sustaining an injury, one may find it difficult to perform activities of daily living (ADLs), which include bathing, dressing, grooming/hygiene, toileting, and feeding. Occupational therapists can help patients develop skills needed to complete their ADLs as independently as possible.

It may also be necessary to use adaptive equipment—devices that are used to assist with completing ADLs. Past studies have shown that these pieces of equipment are readily employed for chronic lower back pain in hospital settings (about 88% of devices in the study were used and 85% were considered beneficial). In addition, increased frequency of use and perceived benefit of the adaptive equipment were associated with the number of occupational therapy sessions provided.14

Studies have shown there are 5 factors that predict whether patients will adapt these devices for home use, including: medical-related (diagnosis or other medical condition); client-related (age, gender, and satisfaction of equipment); equipment-related (suitability, replacement, and delivery); assessment-related (adequate assessment and home visits); and training-related (frequency of sessions and training of caregiver).15

The following examples of adaptive equipment are commonly prescribed to patients who suffer from chronic pain. This is just a small sampling of the equipment that may be used to increase independence (Table 3).16

Bathing

In the first few days or weeks following injury, one may not be able to bathe regularly and may take sponge baths in bed. Once one is medically stable and cleared by the physician for showering, the occupational therapist can help patients learn how to shower safely using certain adaptive equipment, such as a long-handled sponge and/or a shower chair.

The long-handled sponge is designed for use by individuals with upper-extremity or mobility disabilities or limited range of motion. A shower chair is usually a sturdy seat made from corrosion-resistant aluminum tubing. It has a curved, textured plastic seat with drain holes and handles to allow easy and safe transfer. The legs are fitted with anti-slip, non-marking rubber feet.

Dressing

Upper-body dressing includes putting on and taking off any clothing items from the waist up. Lower-body dressing includes putting on and taking off any clothing item from the waist down.

When dressing the lower body, persons with pain might find it helpful to use a combination of adaptive equipment. The most common position for performing lower-body dressing is sitting at the edge of the bed; this allows the person to maintain balance. Some of the most common pieces of adaptive equipment used during dressing may include a pick-up stick (or “reacher”), a long-handled shoehorn, a sock remover, elastic shoelaces, a sock lead (or stocking aide), and a leg grip (or lift strap).

The “reacher,” or pick-up stick, can help patients pick up objects (up to 5 lbs.) off the floor without straining their back. It can also be used to reach items on the top shelf of the cupboard. The long-handled shoehorn reduces the need to bend when putting on shoes or slippers. It features a handle grip providing a comfortable hold. The function of the sock remover is its namesake. Patients can also use elastic shoelaces to turn any shoes into slip-ons. Patients will never have to tie laces again when using curly elastic shoelaces. Simply thread the curly laces in, pull them snug, and shoes are always ready to slip on.

The sock lead, or stocking aide, allows patients to put their socks or stockings on with ease. Ideally, the sock lead is for those who have difficulty bending at the waist. The patient holds the sock or stocking firmly in place while pulling it around the foot. Finally, the leg grip, or lift strap, is a simple but practical leg lifter that is useful for people with limited lower-extremity strength. It enables patients to lift the foot onto a wheelchair footrest, bed, or into a car. It is also used to stretch the hamstrings while in physical therapy.

Grooming/Hygiene

Grooming tasks include brushing teeth, washing face, combing hair, shaving, and applying makeup. Most individuals can complete grooming without difficulty from a chair as long as items are in reach. For other people, including persons diagnosed with a tetraplegia level of injury, grooming becomes more difficult and is usually completed in a supported, seated position in bed or in a wheelchair. Once a patient can tolerate a sitting position, the occupational therapist will help them practice techniques to complete these activities as independently as possible using adaptive equipment, such as a foot brush and an inspection mirror. The foot brush and the inspection mirror are both self-care aids designed for use by individuals with diabetes, mobility disabilities, and/or arthritis. The foot brush comes with a sponge that a patient can use for cleaning between toes and applying medication.

Toileting

Toileting includes the ability to pull down clothing in preparation for elimination, cleaning of the rectal and genital areas, and pulling clothing up after completion. Individuals are often able to independently complete the process with the correct technique and needed equipment. Toileting for some individuals, especially persons diagnosed with a tetraplegic level of injury, is usually difficult. The occupational therapist will develop a specialized toileting program for patients/caregivers for home use. Adaptive equipment may include a toilet paper holder. This toilet tissue aid is a simple solution for people who need an extended reach to their rectal or genital area. The spring clamp on this toilet tissue holder easily opens to release tissue paper. This bathroom aid is ideal for persons who are disabled, obese, or small in stature.

Feeding

Feeding is usually not difficult for most individuals, including persons diagnosed with a paraplegic level of injury. This activity, however, can be difficult for others including a person diagnosed with a tetraplegic level of injury. Feeding is usually done in a supported seated position in bed with a bedside table or from wheelchair level with a lap tray. There are several pieces of adaptive equipment available to assist with this process, including adaptive utensils, scoop dishes, long-handled straws, one-handed cutting boards, and can openers.

Medical Devices

Adaptive devices differ from medical equipment, which is designed to aid in the diagnosis, monitoring, or treatment of medical conditions. There are several basic types of medical equipment, including: diagnostic (ultrasound and x-rays); treatment (infusion pumps); life support (ventilators and dialysis machines); medical monitors (blood pressure monitors); medical laboratory (blood and urine analyses); and therapeutic devices.

How Effective Are Therapeutic Devices?

Therapeutic devices are used for healing purposes and in combination with physical therapy.17 Examples of therapeutic devices include low-level laser therapy (LLLT), transcutaneous electrical nerve stimulation units (TENS), acupuncture, spinal cord stimulator (SCS), and therapeutic ultrasound. LLLT utilizes low-power lasers claimed to stimulate tissue and encourage cells to function. There has been a lack of consensus over its scientific validity, but specific test and protocols for LLLT suggest it may be mildly effective. There is evidence to support its efficacy in relieving pain conditions, such as rheumatoid arthritis,18 osteoarthritis,19 and neck pain;20 it may also be feasible for chronic joint disorders.21 The evidence for LLLT in the treatment of low back pain is unclear.22,23

A TENS unit is typically a battery-operated device that applies currents to the transcutaneous layer of the skin through 2 or more electrodes and is used for nerve excitation to suppress pain.24 In principle, an adequate intensity of stimulation is necessary to achieve pain relief with TENS, and patients report the sensation as strong but comfortable. Evidence supporting the use of TENS for chronic musculoskeletal pain has been inconsistent.25,26 Other studies have found no clinically significant benefit to TENS for the treatment of neck pain27 or chronic low back pain,28 but it may be helpful for diabetic neuropathy.29 More recently, a head-mounted TENS device, Cefaly, was approved by the FDA in 2014 for the prevention of migraines.30

Acupuncture is the practice of inserting and manipulating needles into the superficial skin, subcutaneous tissue, and muscles of the body at particular acupuncture points. Acupuncture is commonly used for pain relief,31,32 though it is also used for a wide range of other conditions. There is promising scientific evidence to support the use of acupuncture for chronic pain conditions, such as arthritis and headaches, and limited support for neck pain.33

The SCS is used to treat chronic and intractable pain, including failed back surgery syndrome, complex regional pain syndrome, and phantom limb pain.3 Neurostimulation involves surgically implanting microelectrodes in the epidural space and an electrical pulse generator in the lower abdominal area or gluteal region and uses electrical impulses to block pain. Candidates for spinal cord stimulation must undergo a medical and psychological evaluation, trial procedure (1 week), final implant surgery, and follow-up with a gradual decrease of medications.34

Therapeutic ultrasound is a deep heating modality that is produced by sound waves and then absorbed by body tissues and changed to thermal energy. Physiological effects of therapeutic ultrasound are increased tissue temperature and pain threshold. The effectiveness of therapeutic ultrasound for pain, musculoskeletal injuries, and soft tissue lesions remains questionable.35,36

Acknowledgments

The authors thank all the veterans and providers who contributed to the Pain Education School program from which this tutorial was created. The authors would especially like to thank Socrates Capili, PT, and Julie Seltzer, OTD, OTR/L, for their contributions in teaching about proper body mechanics and self-care aides. The authors would also like to thank the Jesse Brown VA Medical Center Anesthesiology/Pain Clinic department for their vision and ongoing support of the Pain Education School program, all located in Chicago, Illinois.

Last updated on: May 17, 2016
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Pain and Weather—A Cloudy Issue

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