___________________________________________________ Pain Assessment and Management, 2nd Edition
EXAMPLES OF INTERVENTION APPROACHES
Education
Adaptive equipment identification and training, positioning equipment and strategies, functional mobility training, range of motion and strengthening exercises Activity pacing and energy conservation, ergonomic and body mechanics, fall prevention programming, activity analysis and modification Transportation training, community reintegration, compensatory cognitive strategies, education and disease self-management training, pain coping strategies, communication strategies Medication management, self-regulation and stress management, eating routines, physical activity engagement, time management, advocacy and self-advocacy, sensory strategies Cognitive behavioral therapy for insomnia, energy conservation and fatigue management Academic and work accommodations, gradual reentry plans, environmental modifications Community and online resources, strategies to prevent social isolation, values and interests exploration, community reintegration
Activities of daily living (ADLs) Instrumental activities of daily living (IADLs) Health management
Rest and sleep
Education and work Play, leisure, and social participation
Source: Adapted from Reeves et al. (2022)
Table 6
Superficial Thermal Modalities Superficial thermal modalities alter the temperature of the soft tissue through either conduction or convection (Walter & Winston, 2018). Application of thermal modalities (heat or ice) to injured tissues decreases pain, improves circulation, increases tissue extensibility prior to stretching, and hastens the healing process (Walter & Winston, 2018). Heat may be applied in the form of hot packs, heating pads, fluidotherapy (a dry heat modality that uses a suspended airstream with the properties of a liquid), and paraffin (melted wax) baths. Cryotherapy, or cold therapy, is commonly used by practitio- ners to treat acute injuries by decreasing pain, inflammation, and edema (Bracciano, 2008; Walter & Winston, 2018). The cold therapy methods most commonly used to decrease pain are cold packs, ice massage, cold-water immersion baths, cool whirlpools, ice towels, and vapocoolant sprays (Bracciano, 2008; Walter & Winston, 2018). Thermal modalities should be applied carefully because there is an increased risk for burns or frostbite in clients who have decreased sensation or impaired circulation. Deep Thermal Modalities Deep thermal agents use conversion to push heat deep into the tissues (Walter & Winston, 2018). Therapeutic ultrasound is most often used as a form of deep heat to facilitate the heal- ing process (Walter & Winston, 2018). Due to the ability to reach deeper tissue, this modality has the potential to treat conditions that include joint contractures, scarring and the resulting adhesions, and muscle spasms (Walter & Winston, 2018). The use of therapeutic ultrasound has been found to have a positive effect on pain and quality of life for a number of conditions; however, the effects are not long lasting (Balci et al., 2018; Boyraz et al., 2015; Király et al., 2017; Reda & Eman, 2016). More recently, ultrasound was found to be not supported as an intervention specific to low back pain and was listed as “don’t do” in the clinical practice guidelines for primary care (Meroni et al., 2021, p. 15).
Iontophoresis Iontophoresis uses electrical currents to deliver medications or ionized drugs; the benefit of this treatment is that the medication stays localized to the treatment area and has little interaction with any oral medications that a client may be taking (Walter & Winston, 2018). Medications can include glucocorticoids (e.g., dexamethasone), NSAIDs, lidocaine, and opioids. The modality includes a power source, a medicated electrode, and an indifferent electrode. The power source is often a battery-powered unit that can deliver a current. The medicated electrode holds a chamber in which the medica- tion is stored prior to delivery, and the indifferent electrode completes the circuit of the current, enabling the medication to be pulled into the skin (Walter & Winston, 2018). Although iontophoresis has been used to treat pain for approximately 30 years, studies to measure its effectiveness have been limited by small sample size ( Mendonça et al., 2019). Iontophoresis is commonly used for musculoskeletal injuries such as tendinitis. Mendonça et al. (2019) found only low to very low evidence to support the short- and long-term effects of iontophoresis. Gulkesen and Ardicoglu (2018) found that the use of steroids with iontophoresis was not supported for clients who experience rheumatoid arthritis and wrist syno- vitis. Shingala and Gill (2018) found both iontophoresis and phonophoresis were equally effective for treatment of lateral epicondylitis. Other studies support the use of iontophoresis as an adjunct therapy (Thakur et al., 2017). Electrotherapeutic Modalities: Transcutaneous Electrical Nerve Stimulation (TENS) A widely used modality for the reduction of pain is transcuta- neous electrical nerve stimulation, more commonly referred to as TENS (Safdar et al., 2017). TENS uses stimulation at different intensities through an active electrode over a painful area (Karasuno et al., 2016). There are two primary theories to explain why TENS is effective: Gate theory and endorphin theory (Bracciano, 2008). Gate theory proposes that TENS interferes with nociception by blocking its transmission along
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