Physiatric procedures in pain management - Physical modalities

The most important strategy in pain management is to identify and treat the etiological lesion that causes pain. Generally, the soft tissue lesions should be treated conservatively with non-invasive techniques (manual therapy, physical therapy, etc.) prior to the consideration of aggressive therapy with invasive techniques (needling, injection, surgery, etc.). Physical modalities are effective tools for pain control and also for elimination of soft tissue lesions. The most commonly used modalities include thermotherapy, electrotherapy, mechanical traction, and laser therapy. The selection of appropriate physical modalities should be based on the nature, the location, and the chronicity of the lesion. Heat (thermotherapy) can cause vasodilatation and improvement of local circulation. It is usually applied in combination with other modalities or manual therapy. Considering the vasoconstriction effect, Cold therapy should be used only for bleeding control and pain control in acute injury or in an extremely severe active inflammation that is very uncomfortable. Electrotherapy is effective for pain control and muscle relaxation. For temporary pain relief, nerve stimulation (such as transcutaneous electrical nerve stimulation) can be used. For muscle relaxation or for myofascial pain therapy, muscle stimulation is recommended, since the muscle contraction caused by the electrical stimulation is similar to focal massage. Mechanical traction to cervical or lumbar spine is also frequently applied to treat the facet joint lesion, disc lesion, or paraspinal muscle spasm. The weight, duration, and angle of pulling are critical to determine the effectiveness of traction. Laser Therapy has been recently used for pain control, but the mechanism is still unclear. Other modalities including iontophoresis, phonophoresis, vibration, shock waves have been also applied for pain control. However, the real therapeutic effectiveness and their scientific basis are still not well established. In clinical practice, pain control is usually performed with a combination of different methods including physical modalities, manual therapy, exercise therapy, needling, etc. A clinician can make choice of any combination based on his own preference or patient's preference. However, it should be based on a founded scientific wisdom.