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19 Articles in Volume 20, Issue #4
20/20 with Dr. Nathaniel Katz: Pain Research and Future Therapeutics
A 20-Year Timeline: Pain Therapeutics and Regulations
A Comparison of the Alpha-2-Adrenergic Receptor Agonists for Managing Opioid Withdrawal
A Pain Assessment Primer
After the Task Force: A Conversation with Vanila A. Singh, MD
Ask the PharmD: Can opioids and benzodiazepines ever be used together?
Cognitive Strategies and Mindful Awareness for Integrative Pain Care
COVID: Clinical Considerations for Acute and Post-Infection Symptoms
Editorial: Fudin and Gudin Tackle Pain Care History – Asking, Have We Done a 180?
From Hands-On to Home-Based Care: Physical Therapy Undergoes a Paradigm Shift Due to Pandemic
MS-Related Pain and Spasticity: Are Cannabinoids an Option?
New Biological Agents for Psoriatic Arthritis: A Monoclonal Antibody Primer
Pandemic Presents Unexpected Opportunity to Embrace Multimodal Analgesia and the Integrative Care Team
Provider Perspective on Knee OA: Injections and RFA Options
Redefining the “Pain Specialist” of Today
Resident’s Corner: Climbing the Learning Curve in Pain Management
The Evolution of Pain Management: Experts Weigh In
Tips from the Field: How to Enhance Practice Efficiency
Tumor Necrosis Factor (TNF) Inhibitors: A Clinical Primer

From Hands-On to Home-Based Care: Physical Therapy Undergoes a Paradigm Shift Due to Pandemic

A provider’s perspective on how the coronavirus has reshaped physical therapy and pain rehabilitation services. Plus, clinical recommendations for exercises and devices patients can use at home.

This period in our history has been difficult in so many ways, testing our resolve as a nation and our resilience as a community. However, difficult times inspire innovative solutions and on the physical therapy and rehabilitation front, we are switching gears.

The SARS-CoV-2 pandemic has – perhaps unexpectedly - provided us with an opportunity to gain insight into what patients deem important in the long term. This provider perspective details how my clinic has adjusted care and where our practice sees things settling.

 

Clinicians Shift Service Options

In keeping with state-mandated orders to provide only essential and emergency services, my outpatient physical therapy pain practice in Ypsilanti, Michigan, has reduced patient volume by 90% since February 2020. Our staff is practicing social distancing and mask-wearing. Those patients entering our clinic consist primarily of post-operative patients and those unable to control their pain through pharmacotherapy alone.

This forced break in our usual two- or three-sessions-a-week routine for physical therapy (PT) patients has created what in research we call a “washout period” – that is, a time period when the experimental intervention fades until there is no longer any remnant and the next step is taken without concern for contamination.

For patients, it has washed away the habit of coming into therapy simply because that’s what you are supposed to do and/or what their doctor prescribed. Those patients who felt any degree of ambivalence about the benefits of PT now have the perfect excuse to discontinue without feeling guilty or be labeled as noncompliant.

It will be interesting to see the effects of this mandated service delivery break on re-enrollment of patients once executive orders around the closure of non-essential businesses are lifted. In the meantime, we have been communicating to patients that staying physically active is crucial to both musculoskeletal (MSK) and overall health, and we have been providing them with exercises and a structured plan to follow (more on this below).

From the practice angle, we recognize that the true value of PT services can only be measured by the end-user (ie, the patient). So for small businesses like mine, a few questions have arisen: Do we have to be all things to all patients, and will they think any less of us if we are not? How do we continue to provide services to those patients who wish to continue? Do they need to be present in person? What about those patients who do not want to continue but, clinically speaking, should?

While telemedicine has served as an answer to many provider communities, PT is about hands-on service provision. Initially, I could not imagine what type of virtual visit would be worthwhile to a patient. But after challenging my own assumptions, I have discovered some value associated with this alternative.

Soon after our state went into “lockdown,” my practice decided to remain committed to the idea that our services were best delivered face-to-face and that virtual sessions – in the scope of physical therapy – benefitted the provider more than the patient. We found, however, that many of our patients were not only willing to become more self- responsible, they fully expected it. They did not wish to simply stay home and wallow in pain until facilities reopened; they wanted to be guided through a home pain therapy plan and virtually coached through any queries or problems. And so, with the spread of infectious disease, our old ways of doing things went out the window and we welcomed a new service delivery model (imperfect as it was).

Below are some of the tools and regimens we have been using to provide relief remotely to our pain patient population during this time of crisis.

 

Image: iStock (kate_sept2004)We are sharing with our patients exercise illustrations, along with step-by-step instructions as to the number of repetitions and sets, which we then review via video telemedicine for proper form and to answer any questions.

Home-Based Interventions that Can be “Prescribed” for Pain

 

Exercise and Training Regimens for Pain Relief

We have shared with our patients exercise illustrations, along with step-by-step instructions as to the number of repetitions and sets, for each of the programs below, which we then review through a telemedicine/video visit for proper form and to answer any questions.

 

Stretching: By far, the most requested “do-at-home” intervention from our patients has been the provision of varied stretches for whatever area is hurting. Although the exercise science literature on stretching has not been 100% supportive of the performance benefits associated with improving flexibility, the rehabilitation literature has been more optimistic regarding the use of soft-tissue stretching as a means to reduce disability.1,2

Specific stretches can help to reduce pain and make muscle contraction more efficient.3 Stretches can also release entrapped nerves and elongate painful and restrictive scar and fibrotic tissue.4,5

Stretching programs can be illustrated to show patients proper form and to guide them through the specifics, such as right or left side, number of repetitions, hold time, and the number of sets and sessions per day (see Figure 1, Spine Stretch and Figure 2, Hip Stretch).

Resistance Training: Another prominent request from patients has been for exercises that build strength, stamina, and endurance in the muscles and in the heart and lungs (cardiopulmonary), as well as for aerobic exercises.

Apart from compliance, strength training is well recognized to reduce musculoskeletal (MSK) pain.6,7 There are many simple and inexpensive ways that a resistance circuit can be devised using stationary objects, leather belts, or even a table leg. Our practice has also mailed TheraBand kits to some patients (see Figure 3, Shoulder Stretches with Bands). These bands are heavy duty resistance bands that are color-coded according to tensile strength.

Core Stability Training: Core training, not just for strengthening purposes but also as a motor control exercise, can link MSK  functions with genito-urinary regulation,  including incontinence which is a significant problem in people of all genders and ages.8,9

The training stimulus for stabilization exercises is different than stretch, strength, or aerobic training exercises in that stability training is done daily and is not meant to be effort-based. Training adaptations are not related to increases in fiber diameter or cross-sectional area of muscle but rather, work more like a switch that is turned on or off.

The use of ultrasound imaging has elucidated the value of using dynamic and destabilizing motions during core training exercise to maximize the magnitude of the core activation response.10,11 Figure 4 provides an example of a simple core exercise that most people can do using a stability ball as a prop.

 

Pain-Relieving Devices for Home Use

Several devices have demonstrated effectiveness at providing clinical-grade pain relief in the home setting which is often preferred and should almost always be considered over prescription pain medicine – some of which can raise kidney or liver toxicity concerns – when possible. These devices are time-tested and have virtually no universally acknowledged adverse effects when used according to their instruction manual.

Each device approaches pain relief via a different mechanism of action (MOA). Below are a few options I have used with and recommended to my patients, but there are many more available and worth exploring.

 

Electrotherapy. The use of transcutaneous electrical nerve stimulation (TENS) and microcurrent nerve stimulation (MENS) offer low costs and wide availability.

The TENS device applies an electrical current to the surface of the skin that is designed to stimulate cutaneous nerve endings. The spinal cord is thereby flooded with “noise” so that the pain signal no longer registers in the brain. Depending on the stimulation parameters, these units may stimulate the release of endorphins/enkaphalins and dynorphins as well.

MENS, also referred to as subliminal stimulation, uses exponentially less amperage. But do not let the current strength fool you - it can provide powerful pain relief. The lower current accompanied by changes in pulse frequency equates to less skin resistance and improved impedance so that the target tissue receives all the stimulation it needs to promote healing and recovery.12

As with any modality, not all patients may respond to these devices.

Example: VibraCool.  More on whole body vibration for pain management.

Willow Curve (image courtesy of manufacturer)

 

Phototherapy/Light Therapy. The use of light therapy can include applications involving light emitting diodes (LEDs), infra-red and/or ultraviolet lamps, and laser devices – each with its own proprietary nuances. It is not the purpose of this report to provide comparative effectiveness but most of these devices have found a place in either human performance or rehabilitative care of injury and recovery of function.

Example: The Willow Curve is one example of a combination LED/laser device that available to the public without medical prescription. This device can provide medical-grade pain relief at an affordable price and  has a wide array of applications from wound healing to straight-forward pain relief using infra-red light combined with artificial intelligence. Our practice has found this device to be popular among patients.

More on light therapy/photobiomodulation for chronic pain conditions.

 

Vibration Technology. The literature on exercise science and health and human performance has grown exponentially over the past decade, especially regarding the use of vibration devices. Whole body vibration training (WBV) has become a staple at many fitness and anti-aging centers across the country as an exercise recovery intervention13 but continues to be rather controversial. For pain relief, there is evidence supporting the use of these WBV plates/platforms for conditions such as chronic non-specific lower spine pain in that the technology may induce musculo-tendinous changes in soft tissue architecture.14,15

Examples: Our team has found that traditional WBV devices typically provide general pain-relieving effects, however, these devices are not necessarily feasible or available for home use.

A new portable and more specific device (VibraCool) was developed not long ago and has become a popular home pain device. Originally developed for pediatric application (Buzzy) to provide numbness over a topical area that is about to be inoculated, this device can provide adult-sized analgesia in a matter of minutes by simply placing it over the painful body part. The device has a wide spectrum of usage, from sports injuries to chronic idiopathic pain in the sacroiliac region or lower spine.

The Oska Pulse is another option. See prior review

 

NormaTech (image courtesy of manufacturer)

 

Vasopneumatic/Compression Devices. The use of compression sleeves for the lower or upper body has grown in application after research suggested it may have benefits beyond removing excessive extracellular fluid. There is evidence to suggest that intermittent decompression may cause epigenetic changes in muscle, for example, that would stimulate both capillary and protein expression –benefits from both a human performance and human disability (sarcopenia) perspective.16,17

Evidence continues to grow regarding the use of intermittent decompression in accelerating the recovery of exercise-induced soreness and even stimulating improved muscle function compared to passive recovery as well.18

Example: Our facility has used the NormaTech device to treat persistent swelling in the extremities from lymphedema or secondary to orthopedic surgery, but also as a post-workout recovery tool that facilitates resolution of delayed onset muscle soreness.

 

Looking Ahead

Although many challenges have been set into motion for the medical community – and so many others – it would be disappointing to not use this time as an opportunity to embrace change and explore innovation. In the physical therapy and pain rehabilitation setting, telemedicine and virtual platforms have placed greater emphasis on home-care and self-care options for our patients.

While our face-to-face communication has shifted from hands-on service provision to verbal coaching and visual demonstrations, these contingency options may very well have longer-term, unintended benefits. As patients come to better understand the limitations of our medical and public health systems, they will value having a home pain therapy plan in place for the next potential public health crisis.

 

All exercise figures provided by the author. The author has no financial or other ties to the products/manufacturers mentioned.

PPM's COVID and Pain Management Resource Center (updated regularly)

Last updated on: August 3, 2020
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