"Given the choice between the experience of pain and nothing, I would choose pain"                                             William Faulkner

In earlier times, it was thought that the best way to manage pain was to place a person on bed rest until the pain subsided. This was the treatment of choice for several centuries before it was discovered that both chronic and acute pain were often more responsive to exercise than to rest. Indeed, excessive rest causes muscles to stiffen and shrink, and reduces circulation, thereby causing soreness to linger.

Physical Therapy & Therapeutic Exercise

There are two kinds of physical therapy (PT), the active and passive types. Physical Therapy addresses the musculoskeletal aspects of chronic pain problems. When PT is ordered by a physician, a thorough evaluation is performed by a therapist who is trained in assessing people of all ages, and all diagnoses and disabilities. Following the evaluation, an individualized treatment plan is developed, incorporating manual therapy, pain-relieving modalities, and an easy, effective exercise program.[i]

Examples of passive physical therapy includes heat/ice packs, TENS units, and ultrasound.

       Two kinds of spinal cord stimulation systems are available. The unit that is more commonly used is fully implanted and has a pulse generator and a non-rechargeable battery. The other system includes an antenna, transmitter, and a receiver that relies upon radio frequency. The latter systems antenna and transmitter are carried outside the body, while the receiver is implanted inside the body. Spinal cord stimulation is recommended when other treatments have not been successful, when surgery is not likely to help, or when surgery has failed.  

• Ultrasound: Ultrasound is a deep heating modality that is effective in heating tissues of deep joints. It has been found to be helpful in improving the stretchiness of connective tissue. It is not indicated in acute inflammatory conditions where it may worsen the inflammatory processes at play. Ultrasound therapy typically provides only short-term benefits when used in isolation, but can be useful in combination with more active forms of PT, and with therapeutic massage.[ii]

      Examples of active PT include stretching and strengthening exercises, pain relief exercises, and low-impact aerobic conditioning. These gentle forms of exercise are recommended for musculoskeletal pain shortly after acute pain subsides following an injury or surgery. Active forms of exercise are almost always necessary to help alleviate joint and back pain.

When done in a controlled, gradual, and progressive manner, active exercise distributes nutrients into the soft tissues to keep the discs, muscles, ligaments and joints healthy. Consequently, a regular exercise routine helps patients avoid stiffness and weakness, minimize recurrences of pain, and reduces the severity and duration of possible future episodes of pain.

To treat back, hip, and leg pain, the most important muscles to target are:

• Hamstrings, in the back of the leg, to aid correct posture while sitting and standing, and support the gluteus muscles in the buttocks and the hip flexors and minimize stress on the low back.  
• Piriformis, which run from the back of the femur (thigh bone) to the sacrum (the base of the spine). When tight, this muscle can cause sciatica-like pain, and has been linked to sacroiliac joint dysfunction. 
• Psoas Major which is attached to the front portion of the lower spine and can greatly limit low back mobility if tight, making it hard to stand for extended periods or kneel on both knees.  
• Gluteus muscles of the buttocks which support hip flexibility as well as the pelvis

      Stretching should be done daily, perhaps several times a day, to ensure flexibility. Additionally, developing strong core muscles in the abdomen, lower back and gluteus is critical to decreasing the stress placed upon the lower back. Many different exercises can contribute to overall strengthening of these core muscles.[iii]

Cognitive-Behavioral Methods

A number of methods based on the mind-body connection exist to treat chronic pain. In these treatments, a patient’s thinking, stress responses, and mental reactions to pain are targeted for adjustment.

Cognitive-behavioral therapy (CBT) teaches relaxation techniques, stress management, and other ways to help a person cope with pain. Physical, psychological, and social factors all play a role in pain management.

       Cognitive-behavioral therapy is based on the idea that thought and behavior patterns can affect symptoms and disability, and may be obstacles to recovery. For example, when a patient feels a familiar type of pain starting or getting worse, they likely have a sense of how it will progress. If the person is used to the pain being severe or long-lasting, they may expect the pain to become more intense. This thinking may make him/her feel out of control or helpless. A stress response like this can trigger physical changes in the body, such as a rise in blood pressure, the release of stress hormones, muscle tension, and more pain.

In addition to group and individual psychotherapy, a qualified counselor will assign the patient with chronic pain “homework” to encourage them to change the way they respond to pain. Often, they are taught to relax into the pain, do breathing techniques that reduce the perception of pain, and send themselves positive affirmations that are designed as self-reminders to the patient that they can control what is happening to their body.

Biofeedback is another cognitive method used for the treatment of many common pain problems, most notably headache and back pain. Using a special electronic machine, the patient is trained to become aware of, to follow, and to gain control over certain bodily functions, including muscle tension, heart rate, and skin temperature. The individual can then learn to effect a change in his/her responses to pain by using relaxation techniques. Biofeedback is often used in combination with other treatment methods, generally without side effects. Similarly, the use of relaxation techniques in the treatment of pain can increase the patient's feeling of well-being.

Hypnosis as a remedy for pain continues to grow in popularity, especially as an adjunct to pain medication. In general, hypnosis is used to control physical function or response, that is, the amount of pain an individual can withstand. How hypnosis works is not fully understood. Some believe that hypnosis delivers the patient into a trance-like state, while others feel that the individual is simply better able to concentrate and relax or is more responsive to suggestion. Hypnosis may result in relief of pain by acting on chemicals in the nervous system, slowing impulses. Whether and how hypnosis works involves greater insight-and research-into the mechanisms underlying human consciousness.

Meditation for pain relief has been being used for hundreds of years, but it is only recently that it has become recognized as a great option for relieving various kinds of pain. Meditation for pain relief teaches the body to relax and to focus on things other than the present pain. While learning to meditate to take away pain takes a bit of practice to become effective, there are a variety of benefits that make it worth perfecting. When pain occurs in the body, the body usually responds with adrenaline and the “fight or flight” impulses. By learning to use meditation to relax, the body can help relieve these responses and, in turn, reduce pain.

        Meditation works to focus the mind on other thoughts and feelings. Since the brain cannot preceive two strong stimulus at the same time, the perception of pain is subverted if the mind is strongly concentrating on something other than the discomfort.

Therapeutic activities such as enjoying music, art, literature and play provide welcome distractions from chronic pain and interrupt the stress involved with dealing with daily discomfort. Once engaged in these activities the mind can transport the body to another time and place, leaving behind the aches and pains of the here and now. For some, prayer and religious rituals can serve the same purpose, and give the patient hope and solice. It is recommended that pain patients experiment with a variety of activities to find the one that captivates their attention to the point that they can find enjoyment that is intense enough to give them a brief respite from pain.

Relaxation: Consciously relaxing every muscle in one’s body can help alleviate stress, and allow muscles to release tension that enhances sensations of pain. Often progressive relaxation (tensing and releasing all muscles groups beginning with the toes and working towards the forehead) is accompanied with positive affirmations or guided imagry to transport oneself to a better, albeit imaginary place. With the help of a skilled therapist, pain patients can learn to screen out perceptions of pain by alleviating stress, muscle tension, and generalized anxiety in their lives.

Physical Methods

Therapeutic massage, Chiropractics, Acupuncture, Acupressure and immobilization are all pain management methods that involve touching, holding or manipulating a person’s body in such a manner as to cause pain to diminish.

• Therapeutic massage: Massaging sore muscles obviously reduces pain, but therapeutic massage is really meant as a whole-body approach. Massage gets to the heart of where people feel their pain. There is the overall sense of well-being that one can get from the massage approach. The stress responses in the body associated with pain, such as elevated cortisol levels, are reduced through massage. For these reasons, massage can be used to treat many different kinds of pain. Massage has been found to be effective in chronic pain syndromes involved with arthritis and diabetes; in depressive disorders such as ones that involve addiction like eating disorders; in chronic fatigue and fibromyalgia, and in other autoimmune disorders.

§         Chiropractics: Chiropractic care  is a hands-on therapy based on the theory that dislocations in the spine may cause many medical disorders (especially disorders of the nervous system), all of which cause pain. Chiropractic treatments usually involve adjusting the joints and bones in a person's spine using twisting, pulling, or pushing movements. Some chiropractors use heat, electrical stimulation, or ultrasound to help relax the person's muscles before doing a spinal adjustment. The primary theory behind chiropractic therapy is to help the body heal itself by correcting dislocation of the joints, particularly the bones of the spine

• Acupuncture: Acupuncture is a Chinese therapy that has been used for centuries. It is based on the theory that there is energy, called chi or qi, flowing through the body. Chi is thought to flow along energy pathways called meridians. Acupuncturists believe a blocking or imbalance of the flow of chi at any point on a pathway may result in illness. Traditional Chinese medicine practitioners believe acupuncture unblocks and rebalances the flow of chi to restore health. People often use acupuncture to relieve pain. Western medical researchers who have studied acupuncture believe that it may reduce pain through body chemicals that have calming effects (opioid peptides), or by affecting glands (such as the hypothalamus) that produce substances the body uses. Traditional Chinese acupuncture usually is done by putting very thin needles into the skin at certain points on the body to produce energy flow along the body's meridians. Other types of acupuncture may use heat, pressure, or mild electrical current to stimulate energy flow along these meridians.

• Acupressure: Acupressure is a variation of Acupuncture in which therapists press on acupuncture points with their fingers instead of using needles. Research has shown that acupressure stimulates reactions that cause greater microcirculatory activity in the tissue bed, which in turn produces a more efficient movement of blood at the capillary level. This increases the availability of nutrients, and oxygen, and speeds the removal of the by-products of metabolism. In addition, the increased blood flow warms the muscle tissues. As muscle tissue becomes warmer, strength and flexibility increase. There are other physiological changes related to the increased production of biologically active substances, some of which influence aspects of the nervous system. Patients can even be trained to do self-acupressure using their fingers, or small rubber balls to apply pressure to acupoints for almost immediate pain relief. [iv]

• Immobilization: Braces, corsets, splints, a neck collar, a sling, a support belt, and other devices designed to limit the mobility of the affected joint(s) can also provide some relief from pain by supporting the injured or degenerated area of the body. A wheelchair, power scooter, or a walker allows a pain patient some mobility without putting undue strain on the part of the body that is healing from illness or injury.

Study Questions

Answering the following questions is an optional activity. These questions are provided as a study aid to help you prepare to take the post test.

1. Name the two types of physical therapy. How do these two types of physical therapy work to alleviate pain?

2. Cognitive Behavioral therapies use the mind to overcome physical pain. What is the basic theory that underlies all types of mind-based therapies?

3. Therapeutic massage alleviates a number of secondary conditions that contribute to pain. Name these contributing conditions.

4. What is the difference between Acupuncture and Acupressure? Can they both be self-administered?

5. Devices that immobilize painful areas of the body work in the opposite manner of all of the other therapies mentioned in this chapter. Why are they helpful?