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MODALITIES

 

  • Immobilization: Some times devices such as braces, slings or tapes are used for immbolizing the injured body part. They are used in acute cases to rest the body part so it can heal. In chronic cases, these devices support the painful area but allow it to be used functionally so that muscle strength and joint flexibility are maintained.

 

  • Physical therapy: In acute stages, physical therapist may use passive modalities such as ultrasound to calm down the inflammation. Their job is also to help you maintain your strength, endurance and flexibility in the long run.

 

  • Chiropractic care: These interventions primarily focus on spinal adjustment or adjustment to other joint areas. Chiropractic care may also involve soft tissue therapy, strength training, functional electrical stimulation such as TENS unit, traction, or nutritional recommendations.

 

  • Acupuncture: Acupuncture involves the insertion of needles into acupuncture points in the skin in an effort to relieve pain. Acupuncture relieves pain and inflammation. It can also boost your immune system and help other symptoms such as insomnia, fatigue and low energy.

 

  • Cognitive behavioral therapy: If you are noticing anxiety, depression, stress or any of the other psychological factors mentioned here, you can ask your physician to be referred to a psychologist for cognitive behavioral therapy. They work with you in depth in one on one setting to provide you better psychological tools and coping strategies listed in this website for management of chronic pain.

PAIN PROGRAMS

 

These treatment approaches are based on the biopsychosocial model, one that views pain and disability in terms of the interaction between physiological, psychological and social factors.

 

If the patient has gone through all appropriate diagnostic tests and they do not explain the severity of his pain, if surgery has been ruled out, if he has not been able to return to work for several months, if there is evidence of psychological factors such as anxiety and depression and he is needing increasing amounts of pain medications, then this is the next step in the treatment. 

 

  • Functional restoration program (FRP): Medically directed, interdisciplinary pain management approach geared specifically to patients with chronic disabling occupational musculoskeletal disorders. These programs emphasize the importance of function over the elimination of pain. FRPs incorporate components of exercise progression with disability management and psychosocial intervention. Typically, treatment includes multi-modality approach including medication optimization, exercise, relaxation training, coping skills and stress management. Treatment is provided in an outpatient setting, for several hours a day, every day of the week for several weeks. 

 

  • Early intervention program:  This is a form of FRP, but offered within 3-6 months after an injury.

 

Early intervention is indicated if:

  • If the patient fails to respond to "normal" treatment in a "normal" time frame

  • If the physician cannot explain the severity of his pain based on objective examination

  • Previous medical history of a delayed recovery 

  • Surgery or other invasive treatment is not indicated

  • Inadequate employer support

  • Off work for more than 4 months

  • Evidence of psychosocial barriers

In this section:

TREATMENT GUIDELINES

SELF-MANAGEMENT OF

CHRONIC PAIN

PSYCHOLOGICAL TOOLS

Medications
Modalities
Invasive Treatments
Pain Programs

Without discussing specific treatment for specific injuries, I am going to list the treatment approaches available under the umbrella of Division of Workers' Compensation. You will need to discuss details with your physician. 

MEDICATIONS

 

This is just a brief discussion about the medications used in the treatment of pain. When it comes to chronic pain, you need the guidance of a pain specialist who will optimize your medications, meaning that you get the best pain relief with the least amount of medications and with minimal side effects.

 

  • Anti-inflammatory medications: This is the first line of treatment. Commonly used medications are aspirin, ibuprofen, naproxen, etolodac, meloxicam, and piroxicam. Side effects to watch out for are heartburn and indigestion. With long-term use, they can affect the kidneys.

 

  • Opioids: Most common one being Norco. They cause decreased perception of pain, decreased reaction to pain, and increased pain tolerance. Side effects can include nausea, constipation, drowsiness, dizziness, and vomiting. Long term use can lead to dependence on the medication and possibly addiction, thus need to be closely monitored by a physician.

 

  • Tramadol: It belongs in a category by itself, because it is a pain medication like Norco, but milder, but it also has similar chemical effect as an anti-depressant. The most common side effects are dizziness, sedation, constipation, nausea, and headaches.

 

  • Topical agents: Topical analgesics are applied to the skin and they block the nerve signals from getting to the brain. Topical products are available in various creams, gels, lotions, patches, and plasters. Since they are applied to a localized area externally, topical agents afford a lower risk for systemic adverse events and side effects. Most commonly prescribed topicals are capsaicin, lidocaine, diclofenac, and menthol-methylsalcilate.

 

  • Muscle Relaxants: Muscle relaxants are most commonly prescribed for low back pain, neck pain, fibromyalgia, and tension headaches in situations where muscular contractions appear to be a prominent component of pain. Commonly used are cyclobenzaprine, tizanidine, baclofen, and methocarbamol. They can make you sleepy and thus the recommendation against driving or operating heavy machinery. Other common side effects include dizziness, headache, nausea, irritability, and nervousness. Muscle relaxants can also lead to dependence.

 

  • Other analgesics: These are medications that were originally developed and marketed for uses other than pain but are also used in pain management. The two most common classes of medications that fall into this category are certain types of antidepressants and anticonvulsants. Antidepressants commonly used for analgesic purposes include duloxetine, venlafaxine, and nortriptyline. Anticonvulsants, primarily used to relieve neuropathic pain, include gabapentin, pregabalin, topiramate, and lamotrigine. Common side effects of antidepressants include nausea, vomiting, insomnia, decreased sex drive, and constipation. Common side effects of anticonvulsant medications include dizziness, fatigue, weight gain, and drowsiness.

INVASIVE PROCEDURES

 

  • Epidural Steroid Injections: Epidural Steroid Injections (ESIs) are used for spinal pain radiating down into the arm or leg, caused by conditions such as spinal stenosis or spinal disc herniation. ESIs include a combination of corticosteroids and local anesthesia that is injected into the epidural space around the spinal cord and nerves. The injection may be guided by fluoroscopy or x-ray. The effects of the injection last from one week to six months.

 

  • Nerve Blocks: Nerve blocks can be used for pain in the neck, back, arms or legs. Nerve blocks may include local anesthetic and/or corticosteroids injected directly into the nerve group associated with reported pain. Nerve blocks can be used to treat painful conditions, to determine sources of pain, or to judge the benefits of more permanent treatments such as surgery.

 

  • Trigger Point Injections: Trigger point injections (TPI) are used to relieve knots in the muscle that are not responding to medications. The injection contains a local anesthetic that may include a corticosteroid. Some times, dry needling (no medications) can be used as well.

 

  • Facet Injections: Facet injections are used for those with chronic spinal pain caused by inflamed facet joints. These joints are located between each set of vertebrae in the spine from the neck to the tailbone. A mixture of local anesthetic and corticosteroid medication is injected into the facet joint to reduce swelling and inflammation around the facet joint space.

 

  • Radiofrequency Ablation: Radiofrequency ablation (RFA) is used to treat severe chronic neck or  low back pain. Radiofrequency waves produce high heat on specifically identified nerves surrounding the facet joints in the lumbar spine, ablating the nerves and destroying their ability to transmit pain signals. RFA is an outpatient procedure using local anesthesia.

 

  • Botox: Botox injections are typically used for relief of headaches.

 

  • Corticosteroid injections: Depending on the location of injury and specific diagnosis, a variety of injections are available. Most of these invasive modalities including ESI, facet blocks, nerve blocks and RFA provide temporary relief of pain.

 

  • Spinal Cord Stimulator: The most common use of spinal cord stimulators (SCS) is with patients diagnosed with failed back syndrome, i.e. cases where one or more spine surgeries have been performed and they failed to relieve the pain. A SCS includes electrodes implanted in the epidural space, an electricalpulse generator implanted in the lower abdominal area of gluteal region, connecting wires to the generator, and a generator remote control.

 

  • Intrathecal Pump: An intrathecal pump is an implantable device that delivers pain medication directly to the spinal fluid. Common medications used in pumps include baclofen or morphine. The pumps deliver medications at higher dosages than possible with oral medications.

    SCS and intrathecal pumps are used for rare cases of severe unrelenting pain.

 

  • Surgery: Surgery may be offered for various pain locations such as back, neck, knee, shoulder, or ankle. Surgery for chronic pain is usually considered in rare situations, only after non-surgical treatments have failed.

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