Pain management in physical therapy (Proceedings)

Pain management is a staple factor in the treatment of any physical therapy patient – whether two of four legged. One of the first things physical therapy students are taught in school is how to recognize and identify pain in their patients. Pain and its effects on healing, disease, quality of life, and function are related to each and every patient. Fortunately, significant strides are being made in the treatment of animals with regard to pain.

Physical therapy treatments for pain management are inclusive of many options. Modalities, manual therapies, therapeutic exercise and aquatic activities are some of the many options. A multimodal approach to each patient is essential. In many cases, intervention is required with an appropriate pain medication, non-steroidal anti-inflammatory, and physical therapy. The concurrent care provides the optimal care for the patient. The act of prescribing a non-steroidal anti-inflammatory and/or pain medication should coincide with a referral to physical therapy or rehabilitation. The reduction in pain and inflammation will promote an increase in strength, function, and movement and this will be facilitated through physical therapy.

The first step in the physical therapy process is a referral to physical therapy or rehabilitation. A physical therapist, veterinarian, or veterinarian technician certified in canine rehabilitation should be contacted. These individuals have gone through advanced training through an established program. Once the referral is made and the pertinent case information has been sent, the patient and client will be scheduled for an appointment. The initial evaluation will include a comprehensive history, inclusive of pain patterns, a thorough examination, establishment of a treatment plan and goals, and a treatment. Specific portions of the examination include gait assessment, a lameness evaluation, circumferential measurements to determine muscle atrophy, a neurological and orthopedic examination, range of motion, strength testing, specific pain assessment, and a functional examination. With the results, the physical therapist will establish the goals with the owner. For example, if the dog is demonstrating a pain of five out of ten and is unable to walk up the stairs to the owner's bedroom, appropriate goals will be set. The first level will be to reduce the dog's pain to a three out of ten within the first two weeks of physical therapy and then to a one out of ten within four weeks. The second goal will be to have the dog walk up a flight of stairs with an assistance device such as a sling within two week and then walk up the flight of the stairs independently within four weeks. Treatments will be appropriately set up to obtain these goals. At each visit, the dog is reassessed and the adjustment of the plan and goals will be made if necessary.

Physical therapy treatments are inclusive of modalities, manual treatments, therapeutic exercise, aquatic exercises, adaptive and assistive devices, client education, and home assistance. After evaluating the patient, it is determined what course of action will work most appropriately for the patient. If pain is the primary problem, and the pain level is inhibiting movement, pain will be addressed first through modalities and manual therapies. Once the pain has diminished, functional activities may be performed. The treatment plan is constantly adjusted to meet the needs of the patient.

Modalities available in physical therapy include cyrotherapy, moist heat, laser therapy, ultrasound, electrical stimulation and a combination of electrical stimulation and ultrasound. Cyrotherapy is a method of reducing the pain and inflammation through the applications of ice packs, ice paths or an ice massage. Cyrotherapy removes heat from the surrounding tissues and area, and may reduce the temperature by one to four degrees centigrade intramuscularly and up to thirteen degrees centigrade superficially. It is very effective in acute conditions, postoperatively, and in the management of muscle spasms. It is well tolerated by the animal in most cases and easy to apply.

Moist heat is applied in the form of hot packs, hydrocollators, warm towels and warm baths. The application of moist heat possesses vascular, metabolic and connective tissue effects. It will increase the nerve conduction velocity, decrease pain, decrease muscle spasm, increase connective tissue elasticity and increase circulation to the area. Precautions need to be utilized so the animal is not burned with the application, but it is well tolerated and appreciated by many animals. It is very effective in the treatment of chronic arthritic conditions, restrictions in muscles, as a warm up prior to activity, and for relaxation.

Laser therapy is perhaps one of the most underutilized modalities we have available. Laser is an acronym for the light amplification of the stimulated emission of radiation. Laser acts through the transmission of joules of energy that are absorbed in to the mitochondria of the cells in the form of photons. The energy triggers enzymes needed for various reactions. For example, if an area is inflamed, cell permeability is increased to allow the reduction in swelling. Laser's applications include pain, acute and chronic inflammation, wound management, muscle spasms, arthritis, and others. One of the most researched areas in laser therapy has been wound care but additional research has been conducted and is being conducted in the other areas. It is a very useful modality in the treatment of pain.

Ultrasound utilizes a specific frequency of ultrasound waves to deliver a deep therapeutic heat. A crystal located within the ultrasound head generates sound at a specific therapeutic frequency. There are a variety of indications, yet many precautions for this modality. It is frequently used for deep tissue heating prior to stretching and flexibility exercises, the reduction of muscle spasms, and pain relief. The animal must be shaved prior to the application of ultrasound and an ultrasound gel must be utilized. Precautions and contraindications include metal and plastic implants, decreased sensation, acute edema, infection, neoplasm, and others.

Electrical stimulation may be utilized for pain control, as is commonly referred to as TENS – or transcuteneous electrical nerve stimulation. Electrical stimulation requires electrodes that are placed on the animal to deliver a low dose current to diminish the pain. Treatments range in time from twenty to sixty minutes and are comforting to the animal. The electrodes may be applied directly to the area, over motor points, areas of referred pain, or the nerve roots. The area needs to be shaved and cleaned prior to the application.

Therapeutic massage is a very useful technique in the reduction of pain, edema, muscle spasms, and the improvement of circulation and stimulation. Most dogs respond well to the treatments and the added benefit of relaxation aids in the treatment progression.

Joint mobilization has been used in the treatment of human patients successfully for hundreds of years. The treatment involves the purposeful and passive mobilization of joints to improve mobility and reduce pain. This treatment technique has been proven to be more effective in pain reduction and the restoration of motion when compared to many traditional methods. The application of joint mobilization requires a skilled therapist trained in animal anatomy.