Physical Medicine & Rehabilitation

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A review of rehabilitative principles, modalities, and equipment needs in pain
management.
By David Cosio, PhD and Erica H. Lin, PharmD, BCACP

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.

References
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physiatry.asp#.VVDo_DYcS2w. Accessed May 11, 2015.
• American Academy of Physical Medicine and Rehabilitation. About physiatry: conditions and
teatments. http://www.aapmr.org/about-physiatry/conditions-treatments. Accessed April 21,
2016.
• Cosio D, Lin E, Schaefer DJ. Interdisciplinary rehabilitation: Information for pain practitioners. Pract
Pain Manag. 2015;15(9):51-57.
• PM&R Knowledge Now. Lumbar radiculopathy. http://me.aapmr.org/kn/article.html?id=134.
Accessed April 21, 2016.
• Shiri R, Lallukka T, Karppinen J, Viikarantura E. Obesity as a risk factor for sciatica: a meta-analysis.
Am J Epidemiol. 2014;179 (8):929-937.
• Andersson G. The epidemiology of spinal disorders. In: Frymoyer JW, ed. The Adult Spine: Principles
and Practice. 2nd ed. Philadelphia, PA: Lippincott-Raven:1997;93-141.
• Battié MC, Cherkin DC, Dunn R, Ciol MA, Wheeler KJ. Managing low back pain: attitudes and
treatment preferences of physical therapists. Phys Ther. 1994;74(3):219-226.
• Neal C. The assessment of knowledge and application of proper body mechanics in the workplace.
Orthop Nurs. 1997;16(1):66-69.
• Colorado Comprehensive Spine Institute. The importance of proper body mechanics—keeping your
spine healthy. http://www.coloradospineinstitute.com/subject.php?pn=wellness-body-
mechanics. Accessed May 11, 2015.
• Triplett T, Santos R, Rosenbloom S. American Driving Survey: Methodology and Year 1 Results, May
2013–May 2014. AAA Washington, DC: AAA Foundation for Traffic Safety; 2015.
• Sequin R, Buchner DM, Liu J, et al. Sedentary behavior and mortality in older women, Am J Prevent
Med. 2014;46(2):122-135.
• US Department of Labor, Bureau of Labor Statistics. American tme use survey summary. June 24,
2015. http://www.bls.gov/news.release/atus.nr0.htm. Accessed April 21, 2016.
• Better Sleep Council. A new mattress does the body good. http://bettersleep.org/better-
sleep/healthy-sleep/physical-performance-sleep. Accessed March 31, 2015.
• Tyson R, Strong J. Adaptive equipment: Its effectiveness for people with chronic lower back pain.
OTJR: Occupation, Participation and Health. 1990;10(2):111-121.
• Wielandt T, Strong J. Compliance with prescribed adaptive equipment: A literature review. Br J
Occup Ther. 2000;63:65-75.
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fun.com/disabilities/adaptive-equipment.htm. Accessed May 11, 2015.
• Chou R, Deyo R, Friedly J, et al. Noninvasive Treatments for Low Back Pain. Comparative
Effectiveness Review No. 169. Rockville, MD: Agency for Healthcare Research and Quality;
February 2016.
• Brosseau L, Welch V, Wells G, et al. Low-level laser therapy (Classes I, II and III) for treating
rheumatoid arthritis. Cochrane Database Syst Rev. 2005;(4):CD002049.
• Jamtvedt G, Dahm KT, Christie A, et al. Physical therapy interventions for patients with
osteoarthritis of the knee: an overview of systematic reviews. Phys Ther. 2008;88(1):123-136.
• Chow R, Johnson M, Lopes-Martins R, Bjordal J. Efficacy of low-level laser therapy in the
management of neck pain: a systematic review and meta-analysis of randomized placebo or
active-treatment controlled trials. Lancet. 2009;374(9705):1897-1908.
• Bjordal JM, Couppé C, Chow RT, Tunér J, Ljunggren EA. A systematic review of low-level laser
therapy with location-specific doses for pain from chronic joint disorders. Aust J Physiother.
2003;49(2):107-116.
• Yousefi-Nooraie R, Schonstein E, Heidari K, et al. Low-level laser therapy for nonspecific low-back
pain. Cochrane Database Syst Rev. 2008;(2):CD005107.
• van Middelkoop M, Rubinstein S, Kuijpers T, et al. A systematic review on the effectiveness of
physical and rehabilitation interventions for chronic non-specific low back pain. Eur Spine J.
2011;20(1):19-39.
• Robertson V, Ward A, Low J, et al. Electrotherapy Explained: Principles and Practice. 4th ed. Oxford,
UK: Butterworth-Heinemann; 2006.
• Johnson M, Martinson M. Efficacy of electrical nerve stimulation for chronic musculoskeletal pain: a
meta-analysis of randomized controlled trials. Pain. 2007;130(1-2):157-165.
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https://www.practicalpainmanagement.com/patient/treatments/physical-therapy-
rehabilitation/physical-therapy-rehabilitation
Interventional Pain Management for Chronic Pain
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Injections, Stimulation, Pain Pumps, and Other Treatments

For many people living with chronic pain, finding pain relief can be tough. A lot of trial and error is
involved to find a pain treatment that works. Interventional pain management may help chronic
pain patients cope with their pain.
Similar to other pain management treatments, such as taking prescription medications,
interventional pain management can help you manage your pain. But what makes interventional
pain management different is that it uses techniques, such as injections and radiofrequency
rhizotomy, to directly address the source of your pain.
Some conditions interventional pain management techniques commonly treat include:
• chronic headaches, mouth, or face pain
• low back pain
• muscle and/or bone pain
• neck pain
Sometimes interventional pain management techniques play a part in a multi-disciplinary approach
to relieve your pain and other symptoms. These techniques may be used in conjunction with
mental and emotional therapy and prescription medications, for example.

Below are some of the most commonly used interventional pain management techniques.
Injections
Injections—also called nerve blocks—work to provide temporary pain relief. They send powerful
medications, such as steroids and opioids, onto or near your nerves to relieve pain.
One of the most common injections is an epidural steroid injection in your lumbar spine (low back).
This injection sends steroids directly to the nerve root that’s inflamed.
Other common injections are facet joint injections, single nerve root blocks, and sacroiliac joint
injections.
You’ll most likely need 2 or 3 injections for maximum benefits, but you shouldn’t have more than
that due to the potential side effects of steroids and other medications.
Radiofrequency Rhizotomy
Using x-ray guidance and a needle with an electrode at the tip that gets heated, radiofrequency
rhizotomy temporarily turns off a nerve’s ability to send pain messages to your brain.
Other names for radiofrequency rhizotomy are radiofrequency ablation and neuroablation.
For many patients, this procedure can provide pain relief for 6 to 12 months. During these pain-
free months, however, your doctor will most likely recommend physical therapy. A physical
therapist can help you address underlying physical problems that are causing pain.
Intrathecal Pump Implants
Intrathecal pump implants, also known as pain pumps, provide potent medications straight to the
source of your pain. They’re a type of neuromodulation—a treatment that interrupts pain signals to
your brain.
Pain pumps are commonly used for cancer pain and failed back or neck surgery.
With this procedure, a small device—called a pump—gets implanted under your skin. Your doctor
programs the pump to deliver a specific amount of medication, and he or she will need to refill the
pump every few months.
The main benefits of pain pumps are that they provide consistent pain relief, and if you’re taking
oral medications, you don’t have to rely on them as much.
Because this is a more invasive procedure than an injection, a pain pump is typically used only if
other treatments have been unsuccessful.
Electrical Stimulation
Electrical stimulation is another type of neuromodulation. Similar to a pain pump, something gets
implanted in your body with electrical stimulation. But with this procedure, a stimulator is implanted
along with an electrical lead to send electrical pulses directly to the area that’s causing pain—the
spinal cord, nerves, or brain, for instance.
Electrical stimulation can be used for certain spine conditions as well as conditions that affect your
brain or nerves, such as Parkinson’s disease, epilepsy, and diabetic peripheral neuropathy. You
can have spinal cord stimulation or deep brain stimulation, for example.
Instead of pain, some people feel a tingling sensation with this treatment.
However, as with a pain pump, electrical stimulation is usually one of the last interventional pain
management treatments tried.
Other Interventional Pain Management Techniques
There are other interventional pain management techniques that can help you cope with pain.
Intradiscal electrothermic therapy, for example, uses heat to destroy nerve fibers to reduce your
pain. Another example is cryogenic cooling, which is similar to radiofrequency rhizotomy, but
instead temporarily shuts nerves down by freezing them.
Is Interventional Pain Management an Option for You?
You may need to try several interventional pain management techniques or perhaps a
combination of these techniques as part of a comprehensive pain management plan. These
techniques can provide pain relief to improve your quality of life.
As with any procedure, interventional pain management procedures have certain risks. Have a
discussion with your doctor about whether interventional pain management is an option for you.

Sources
• Interventional Pain Management page. Cedars-Sinai Web site. Available at: http://www.cedars-
sinai.edu/Patients/Programs-and-Services/Pain-Center/Treatments/Interventional-Pain-
Management.aspx. Accessed January 19, 2011.
• Intrathecal Pain Pump Insertion page. Beth Israel Deaconess Medical Center Web site. Available at:
http://www.bidmc.org/YourHealth/MedicalProcedures.aspx?ChunkID=203703. December
2010. Accessed January 19, 2011.
Oakley JC. Interventional Pain Management page. National Pain Foundation Web site. Available at:
http://www.nationalpainfoundation.org/articles/158/interventional-pain-management. Accessed
January 19, 2011.

Physical Therapy and Rehabilitation

If you have a condition associated with chronic pain, such as fibromyalgia or low back pain, it may
seem strange that doing something active—like physical therapy—can actually help alleviate your
pain. But certain physical therapy and rehabilitation techniques can actually help you achieve a
healthier and more active lifestyle.
With physical therapy, a physical therapist can help you improve your range of motion and your
quality of life by creating a personalized, comprehensive treatment plan to reduce your pain and
other symptoms.
To determine your treatment plan, the physical therapist will perform a physical exam to assess
your condition and the severity of your pain. He or she will also ask about your treatment goals
and will work to help you learn how to cope with your pain.

An effective physical therapy treatment plan is one that includes both active and passive
treatments. With passive treatments, you don't have to actively participate in the treatment, but
you do learn to relax your body.
Most physical therapy programs start off with passive treatments but they’ll slowly progress to
active treatments. With active treatments, you’ll learn beneficial exercises to help strengthen your
muscles and deal with your pain and other symptoms.
Passive Physical Therapy Treatments
 Deep tissue massage: You may think that only massage therapists give massages, but
physical therapists do them, too. Deep tissue massage specifically targets muscle tension
caused by strains or sprains or from something more serious. The physical therapist uses
pressure to release tension in your muscles and other soft tissues.
Hot and cold therapies: Depending on your condition, the physical therapist will alternate
between hot and cold therapies. Heat therapy increases blood flow and brings more oxygen
and nutrients to the target area, while cold therapy slows circulation, helping to reduce
inflammation and pain.
Transcutaneous electrical nerve stimulation (TENS): A TENS machine safely stimulates
your muscles at different intensities of electrical current. This therapy can reduce muscle
spasms, and it also may increase production of endorphins—your body's feel-good
hormones.
Ultrasound: Ultrasound can help reduce swelling, stiffness, and pain by increasing blood
circulation. It creates a gentle heat that enhances circulation by sending sound waves deep
into your muscle tissues.
Passive treatments, such as those mentioned above, are generally done with active therapies. For
active treatments, your physical therapist will teach you an assortment of exercises to fit your
needs, particularly to help improve your range of motion, flexibility, and strength.
Also, keep your posture in mind: Along with your personalized physical therapy treatment plan, a
physical therapist will teach you how to properly sit and stand. Applying these small healthy habits
can result in major benefits—they'll help you take better care of your body.
For maximum relief from chronic pain and other symptoms, you may need to incorporate a variety
of physical therapy and rehabilitation techniques into your daily life.

Sources
• FAQ page. American Physical Therapy Association Web site. Available at:
http://www.moveforwardpt.com/faq/. Accessed January 17, 2011.
Physical Therapy page. Federation of State Boards of Physical Therapy Web site. Available at:
https://www.fsbpt.org/ForConsumers/PhysicalTherapy/index.asp. Accessed January 17, 2011.

Physical Medicine and Rehabilitation

http://www.theaba.org/PDFs/Pain-Medicine/PMContentOutline

Temperature modalities (e.g., heat, cold, ultrasound) Manipulation, mobilization, massage, traction Casting
and splinting
Exercise therapy

Other-Treatment of pain (Methods): Physical medicine and rehabilitation