| Institute for Clinical Systems Improvement, 20162 | Summary Recommendations – Physical Rehabilitation Modalities
“Exercise should be a component of the treatment for a patient with chronic pain.
Benefit:
Exercise improves chronic pain symptoms and functional status, and bolsters overall health and sense of wellbeing.
Harm:
There may be potential exacerbation of underlying, or undiagnosed, musculoskeletal injury, cardiovascular or neurologic disease.
Benefit-Harms Assessment:
There is not one particular exercise that is superior, and the optimal frequency has not been demonstrated. The current evidence suggests at least 2–3 exercise sessions per week are necessary for clinical benefit.
Relevant Resources:
Falla, 2013 (Randomized Control Trial); Cuesta-Vargas, 2011 (Randomized Control Trial); Standaert, 2011 (Systematic Review); Dufour, 2010 (Randomized Control Trial); Hall, 2008 (Systematic Review/Meta- Analysis); Hurwitz, 2008 (Evidence Synthesis); Hayden, 2005 (Systematic Review)
Passive modalities should be performed only as an adjunct to a concomitant active physical therapy or exercise program.
Benefit:
Passive physical treatments provide short-term pain relief and potential medium-term benefit.
Harm:
There is minimal risk of harm when applied by trained practitioners.
Benefit-Harms Assessment:
Recommend passive treatments only as a complement to an active therapy or exercise program.
Relevant Resources:
Vincent, 2013 (Systematic Review); Standaert, 2011 (Systematic Review)
Extending physical therapy beyond 8–12 weeks for chronic pain patients should be based on objective clinical improvement.
Benefit:
Physical therapy facilitates rehabilitation and optimizes functional performance in chronic pain patients when used appropriately.
Harm:
There may be additional resources and cost for patients and service providers without evidence of improved outcomes.
Benefit-Harms Assessment:
An active physical therapy program is recommended. Deconditioned pain patients should begin with a graded or progressive physical therapy program to minimize risk of exercise associated injury, and improve patient engagement and compliance.
Relevant Resources:
Cuesta-Vargas, 2015 (Randomized Control Trial); Cramer, 2013 (Randomized Control Trial); Falla, 2013 (Randomized Control Trial); Standaert, 2011 (Systematic Review); Dundar, 2009 (Randomized Control Trial);Koumantakis, 2005 (Randomized Control Trial); Rainville, 2002 (Observational Study)”p.46
Detailed Evidence
“Exercise and Active Physical Therapy
Exercise as a therapeutic intervention is defined as a structured, repetitive, physical activity aimed to improve or maintain physical fitness (Caspersen, 1985). Clinicians should consider the effectiveness, appropriate dose and potential adverse events when prescribing exercise or physical therapy. A patient-centered approach encourages the patient to be an active participant in the treatment program, which improves clinical outcomes (Jordan, 2010). Active therapy is defined as strength training and/or conditioning exercise performed by patients under the direction of a licensed practitioner such as a physician, physical therapist or athletic trainer.
Indications/considerations
All patients with chronic pain should participate in an exercise program to improve function and fitness (Malmivaara, 2006). Formal physical therapy and recreational or self-directed exercise are both beneficial for chronic pain rehabilitation. Exercise under expert direction of a physical therapist has demonstrable efficacy in the medical literature in improving pain symptoms and functional performance in chronic pain patients (Falla, 2013; Cuesta- Vargas, 2011; Standaert, 2011; van Middelkoop, 2011; Hall, 2008; Hurwitz, 2008; Malmivaara, 2006; Hayden, 2005). Since most patients with chronic pain are physically deconditioned from inactivity, graded or progressive physical therapy is recommended. This approach is better tolerated in this population, which improves patient participation and compliance. Progressive therapy focuses on motor learning principles where specific muscular contractions are first learned and mastered before moving on to a sequence of muscular movements with increasing load (Falla, 2013; Jull, 2009; Lindström, 1992). One type of exercise has not been shown to be definitively more effective than another. Studies have shown benefit of flexion exercises, extension exercises, isokinetic intensive machine muscle strengthening, and group aerobic low-impact exercises. Group aerobic exercise and stretching can be as beneficial as structured land-based physical therapy, suggesting this is a reasonable, low-cost alternative for patients (Mannion, 1999). Appropriate indications for aquatic therapy are gait instability, neuromuscular disease, inflammatory or degenerative joint disease, morbid obesity, or deconditioning secondary to acute/subacute medical illness (Dundar, 2009). Two sessions of aquatic therapy per week is equally efficacious as three sessions per week (Cuesta-Vargas, 2015). Active physical therapy for chronic spinal pain conditions should show clinical improvement in pain and function within 8–12 weeks of initiation. Typical physical therapy sessions are 30–90 minutes, occurring two to three times per week, often with an additional daily home exercise program of 10 minutes. If no clinical benefit occurs within this time frame, the appropriateness and efficacy for the prescribed physical therapy should be reconsidered (Cuesta-Vargas, 2015; Cramer, 2013; Falla, 2013; Standaert, 2011). Geriatric patients can benefit from a physical rehabilitation program. The American Geriatric Society Panel of Exercise and Osteoarthritis encourages light- to moderate-intensity physical activity for both prevention and possibly restoration of health and functional capacity in patients with chronic disease (American Geriatrics Society Panel on Exercise and Osteoarthritis, 2001).
Passive Physical Treatments
Passive therapies are defined as the external application of manual and physical treatments to the patient by a clinician. As part of the Choosing Wisely® campaign, the American Physical Therapy Association recommends that clinicians don't employ passive physical agents except when necessary to facilitate participation in an active treatment program. The definitions and indications for conventional passive physical modalities are detailed below.
Spinal manipulation therapy
This is a specific type of manual therapy performed directly on patients by specially trained physicians, chiropractors and physical therapists. It usually involves applying high-velocity low amplitude thrust movements, or slow passive muscle relaxation techniques to increase range of motion and reduce spinal pain.
Indications/considerations
Manual therapies treating chronic non-specific axial neck pain have been demonstrated, in a systematic review of high-quality RCT's, to have moderate short-term efficacy and minimal long-term efficacy. Manual therapies included in this review were typical chiropractic or osteopathic technical procedures: manipulation, passive mobilization and myofascial relaxation techniques. There was not one particular manual therapy superior to the others. A key finding was that concurrent exercise therapy improved the efficacy of all manual therapies (Vincent, 2013). Spinal manipulation therapy for chronic low back pain has similar clinical improvements relative to structured exercise after two months. This was based on a rigorous systematic review, though the evidence for this conclusion is low (Standaert, 2011). Spinal manipulative therapy has been shown to be effective in the early intervention of low back pain (Dagenais, 2010; Walker, 2010; Jüni, 2009; Santilli, 2006; Assendelft, 2004).
Massage therapy
Massage therapy is the manual manipulation of musculoskeletal and connective tissue to improve relaxation and enhance physical rehabilitation.
Indications/considerations:
Massage therapy has been shown to reduce pain scores for patients with low back pain (Hsieh, 2006; Cherkin, 2001), osteoarthritis of the knee (Perlman, 2006), juvenile rheumatoid arthritis (Field, 1997), chronic neck pain (Bakar, 2014) and fibromyalgia (Brattberg, 1999). Yet to be determined are the optimal number, duration and frequency of sessions for treating pain.”p.47 to 48
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Towards Optimized Practice, 20157
Canada | Do
Recommend exercise and therapeutic exercise (Evidence SR)
“Encourage patient to initiate gentle exercise and to gradually increase the exercise level within his/her pain tolerance. Sophisticated equipment is not necessary. Other options may include unsupervised walking and group exercise programs, such as those offered by chronic disease management programs. The peer support of group exercise is likely to result in better outcomes, giving patients improved confidence and empowering them to manage with less medical intervention. When exercise exacerbates the patient’s pain, the exercise program should be assessed by a qualified physical therapist or exercise specialist. If exercise persistently exacerbates their pain, patients should be further assessed by a physician to determine if further investigation, medication, treatment, or consultation is required.
Some studies reported mild negative reactions to exercise programs, such as increased low back pain and muscle soreness in some patients.” P.12
Recommend therapeutic aquatic exercise for chronic low back pain (Evidence SR) p. 12
Yoga (Evidence SR)
“There is some evidence that Viniyoga and Iyengar types of yoga can be helpful in the treatment of chronic low back pain. No evidence was found to recommend other types of yoga It is important to find an instructor who has experience in working with individuals who have low back pain to avoid further injury”p.12
Manual Therapy – Massage Therapy (Evidence SR)
Acupuncture (Evidence SR)
“Recommend acupuncture as a short-term therapy or as an adjunct to a broader active rehabilitation program. No serious adverse events were reported in the clinical trials. The incidence of minor adverse events was 5%.” P.13
Do not know
Manual Therapy – Spinal Manipulative Treatment (Evidence SR)
Manual Therapy – Spinal Mobilization (Evidence SR)
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| Low Back Pain; State of Colorado, Division of Worker’s Compensation, 20144 | Manual Therapy – Manipulation/Mobilization
“There is some evidence that manual therapy, followed by active exercises, may be effective for the reduction of disability from nonspecific low back pain lasting more than 12 weeks.
There is good evidence that spinal manipulative therapy (SMT) is comparable to exercise, standard medical care, and physiotherapy in reducing chronic low back pain, and good evidence that that SMT does not provide a clinically important superior pain relief over these interventions.” p.87
“For subacute/chronic pain, there is some evidence that manipulation/mobilization, including thrust techniques, may provide additional benefits on pain and function when used to supplement an individually tailored exercise program. There is good evidence that two sessions of thrust manipulation of the thoracolumbar spine followed by an exercise regimen leads to better low back function at six months than oscillatory non-thrust manipulation in patients with subacute low back pain.”p.89
Acupuncture
“There is good evidence that acupuncture, true or sham, is superior to usual care for the reduction of disability and pain in patients with chronic nonspecific low back pain, and that true and sham acupuncture are likely to be equally effective.”p.40
Acupuncture is recommended for subacute or chronic pain patients who are trying to increase function and/or decrease medication usage and have an expressed interest in this modality. Credentialed practitioners with experience in evaluation and treatment of chronic pain patients must perform acupuncture evaluations.
Time to Produce Effect: 3 to 6 treatments. Frequency: 1 to 3 times per week. Optimum Duration: 1 to 2 months. Maximum Duration: 15 treatments.
Any of the above acupuncture treatments may extend longer if objective functional gains can be documented and when symptomatic benefits facilitate progression in the patient’s treatment program. Treatment beyond 15 treatments must be documented with respect to need and the ability to facilitate positive symptomatic and functional gains. Such care should be re-evaluated and documented with each series of treatments. All treatments should be accompanied by active therapy.” P. 40 to 41 |
| Canadian Chiropractic Association and the Federation Clinical Practice Guidelines Project, 201312 | Exercise—Chronic Neck Pain.
“Regular home stretching (3–5 times per week) with advice/training is recommended in the treatment of chronic neck pain for long and short-term benefits in reducing pain and analgesic intake (grade of recommendation—strong). This recommendation is based on 3 low-risk-of-bias studies. Home strengthening and endurance exercises with advice/ training/supervision are recommended for both short- and long-term benefits (neck pain, cROM) in the treatment of chronic neck pain (grade of recommendation—strong). This recommendation is based on 4 low-risk-of-bias studies. One additional study with a limiting factor supported this recommendation. In all 5 studies, regular home exercises were performed daily to 3 times per week. Two additional low risk citations with limiting factors found exercises of no benefit. Despite the conflicting results, this recommendation was graded strong owing to the 4 low-risk-of-bias studies.”p.47
Manipulation—Chronic Neck Pain.
“Spinal manipulative therapy is recommended in the treatment of chronic neck pain for short- and long-term benefit (pain, disability; grade of recommendation—weak). This recommendation is based on 1 low-risk-of-bias study with a limiting factor that used 2 treatments per week for 9 weeks.” p.46
Manipulation/Multimodal—Chronic Neck Pain.
“Spinal manipulative therapy is recommended in the treatment of chronic neck pain as part of a multimodal approach (including advice, upper thoracic high velocity low amplitude thrust, low level laser therapy, soft tissue therapy, mobilizations, pulsed short wave diathermy, exercise, massage, and stretching) for both short- and long-term benefit (pain, disability, cROMs; grade of recommendation—strong). This recommendation was graded strong owing to 2 low-risk-of-bias studies. This recommendation is also supported by 5 low-risk-of bias studies with limiting factors that used a number of treatments over several weeks, in addition to assessing the impact of a single treatment over the short term.”p.46
Mobilization—Chronic Neck Pain.
“Mobilization is recommended for the treatment of chronic neck pain for short-term (immediate) benefit (pain, cROM; grade of recommendation —moderate). This recommendation is based on 3 low-risk of- bias studies with limiting factors.”p.47
Manual Therapy/Multimodal—Chronic Neck Pain.
“Manual therapy is recommended in the treatment of chronic neck pain for the short- and long-term benefit (pain, disability, cROM, strength) in combination with advice, stretching, and exercise (grade of recommendation—strong). This recommendation is based on 2 low-risk-of-bias studies. This recommendation is also supported by 2 low-risk-of bias studies with limiting factors.”p.47
Thoracic Manipulation—Chronic Neck Pain.
Massage/Multimodal—Chronic Neck Pain.
“Massage is recommended for the treatment of chronic neck pains for short-term (up to 1 month) benefit (pain, disability, and cROM) when provided in combination with self-care, stretching, and/or exercise (grade of recommendation — moderate). This recommendation is based on 1 low-risk-of bias study and 1 low-risk-of-bias study with a limiting factor. In both studies, 5 to 10 upper body/neck massage sessions lasting 1 hour to 75 minutes were provided.” p.47
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| Multidisciplinary Collaboration including the British Pain Society and British Geriatrics Society, 201313 | Exercise
“Increasing activity by way of exercise should be considered. Exercise should involve strengthening, flexibility, endurance and balance. The preference of the person for the type of exercise should be given serious consideration. Motivation and barriers to exercise and activity should be discussed and planned for. Exercise should be customised to the individual capacity and needs of the person. Maintenance of productive activity and/or exercise should be facilitated.”p.i22
Acupuncture, Massage
“There is limited evidence to support the use of complementary therapies with older adults. What evidence does exist is generally weak and based upon small-scale studies without proper use of controls or randomisation procedures.” p.i23
*No link to grading of evidence provided. No strength of recommendation was made in the guidelines. |
| SIGN, 2013 (Scottish Intercollegiate Guidelines Network)5 | Exercise
“Exercise and exercise therapies, regardless of their form, are recommended in the management of patients with chronic pain.(Grade B) p.5
Advice to stay active should be given in addition to exercise therapy for patients with chronic low back pain to improve disability in the long term. Advice alone is insufficient.(Grade A)” p.5
The following approaches should be used to improve adherence to exercise:
supervised exercise sessions (Grade B) individualised exercises in group settings (Grade B) addition of supplementary material (Grade C) provision of a combined group and home exercise programme. (Grade B) p.28
Manual Therapy (Manipulation and Mobilization)
Manual therapy should be considered for short term relief of pain for patients with chronic low back pain.(Grade B) p.25
Manual therapy, in combination with exercise, should be considered for the treatment of patients with chronic neck pain.(Grade B) p.25
Acupuncture
Acupuncture should be considered for short term relief of pain in patients with chronic low back pain or osteoarthritis.(Grade A) p.29 |
| Orthopaedic Section of the American Physical Therapy Association, 201214 | Manual Therapy
“Thrust manipulative and non-thrust mobilization procedures can also be used to improve spine and hip mobility and reduce pain and disability in patients with subacute and chronic low back and back-related lower extremity pain. (Recommendation based on strong evidence.)” p.3 -4
Interventions – Trunk Coordination, Strengthening, and Endurance Exercises
“Clinicians should consider utilizing trunk coordination, strengthening, and endurance exercises to reduce low back pain and disability in patients with subacute and chronic low back pain with movement coordination impairments and in patients post lumbar microdiscectomy. (Recommendation based on strong evidence.)”p.4
Interventions – Flexion Exercises
“Clinicians can consider flexion exercises, combined with other interventions such as manual therapy, strengthening exercises, nerve mobilization procedures, and progressive walking for reducing pain and disability in older patients with chronic low back pain with radiating pain. (Recommendation based on weak evidence.)” p.4
Interventions – Lower Quarter Nerve Mobilization Procedures
“Clinicians should consider utilizing lower quarter nerve mobilization procedures to reduce pain and disability in patients with subacute and chronic low back pain and radiating pain. (Recommendation based on weak evidence.)”p.4
Interventions – Progressive Endurance Exercise and Fitness Activities
“Clinicians should consider 1) moderate to high intensity exercise for patients with chronic low back pain without generalized pain, and 2) incorporating progressive, low intensity, sub-maximal fitness and endurance activities into the pain management and health promotion strategies for patients with chronic low back pain with generalized pain. (Recommendation based on strong evidence).” p.5 |
| Ottawa Panel, 20129 | Massage Therapy
“The Ottawa Panel CPGs recommends massage therapy as an effective intervention to reduce sub-acute and chronic LBP symptoms and decrease disability at immediate post treatment and short term relief when combined with therapeutic exercise and education. Further research is needed to examine the effects of dosage and technique. Replication of long term effects would allow for greater confidence in this treatment.”p444 |
| Ottawa Panel, 201215 | Massage Therapy
“The Ottawa Panel CPGs recommends therapeutic massage as an effective intervention that may provide an immediate post-treatment reduction in symptoms related to sub-acute and chronic mechanical neck disorders. However, the long-term effects of therapeutic massage are still unclear due to contradicting data, lack of follow up data and a limited number of high quality studies. Future research is needed to examine the role of therapeutic massage as part of a comprehensive, multidisciplinary approach and its long-term effects.”p.316 |
| Chillibeck 201116 | Exercise
Recommendation 2
“Persons with nonspecific chronic low back pain, without serious pathology (i.e., previous back surgery, spondylolysis, spondylolisthesis, neurological symptoms, inflammatory and infectious conditions, or spinal fractures), can safely perform a variety of PAs that are progressive in nature. However, they should initially avoid high-impact PA, heavy resistance training, or extreme trunk flexion, extension, or rotation in a direction that induces pain (Level 2, Grade B).”p.S67
Recommendation 7
“Pregnant women with low back pain can safely perform aquatic exercise (i.e., water aerobics), low-impact aerobics, and pelvic muscle exercises (Level 2, Grade A).” p.S71 |
| State of Colorado, Division of Worker’s Compensation, 201117 | Active Therapy** (Supervised Physical Therapies)
“Active therapy requires an internal effort by the individual to complete a specific exercise or task. This form of therapy requires supervision from a therapist or medical provider such as verbal, visual, and/or tactile instruction(s). Active therapy is intended to promote independence and self-reliance in managing the physical pain as well as to improve the functional status in regard to the specific diagnosis and general conditioning and wellbeing. At times, a provider may help stabilize the patient or guide the movement pattern but the energy required to complete the task is predominately executed by the patient. Therapy in this section should not be merely a repeat of previous therapy but should focus specifically on the individual goals and abilities of the patient with chronic pain.
The goal of active therapy is to teach the patient exercises that they can perform regularly on their own. Patients should be instructed to continue active therapies at home as an extension of the treatment process in order to maintain improvement levels.” P.91
“Aquatic Therapy: is a well-accepted treatment which consists of the therapeutic use of aquatic immersion for therapeutic exercise to promote strengthening, core stabilization, endurance, range-of-motion, flexibility, body mechanics, and pain management.
The pool should be large enough to allow full extremity range-of-motion and fully erect posture. Aquatic vests, belts and other devices can be used to provide stability, balance, buoyancy, and resistance.
Time to Produce Effect: 4 to 5 treatments. Frequency: 3 to 5 times per week. Optimum Duration: 4 to 6 weeks. Maximum Duration: 6 weeks.
A self-directed program is recommended after the supervised aquatics program has been established, or, alternatively a transition to a self-directed dry environment exercise program.”p.91 to 92
“Functional Activities: are well-established interventions which involve the use of therapeutic activity to enhance mobility, body mechanics, employability, coordination, and sensory motor integration.
Time to Produce Effect: 4 to 5 treatments. Frequency: 3 to 5 times per week. Optimum Duration: 4 to 6 weeks. Maximum Duration: 6 weeks.”p.93
“Spinal Stabilization: is a generally well-accepted treatment. The goal of this therapeutic program is to strengthen the spine in its neural and anatomic position. The stabilization is dynamic which allows whole body movements while maintaining a stabilized spine. It is the ability to move and function normally through postures and activities without creating undue vertebral stress.
Time to Produce Effect: 4 to 8 treatments. Frequency: 3 to 5 times per week. Optimum Duration: 4 to 8 weeks. Maximum Duration: 8 weeks.”p.93
“Neuromuscular Re-education: is a generally accepted treatment. It is the skilled application of exercise with manual, mechanical, or electrical facilitation to enhance strength; movement patterns, neuromuscular response, proprioception, kinesthetic sense, coordination; education of movement, balance and posture. Indications include the need to promote neuromuscular responses through carefully timed proprioceptive stimuli, to elicit and improve motor activity in patterns similar to normal neurologically developed sequences, and improve neuromotor response with independent control.
Time to Produce Effect: 2 to 6 treatments. Frequency: 3 times per week. Optimum Duration: 4 to 8 weeks. Maximum Duration: 8 weeks.”p.94
‘Therapeutic Exercise: with or without mechanical assistance or resistance, may include isoinertial, isotonic, isometric and isokinetic types of exercises. Indications include the need for cardiovascular fitness, reduced edema, improved muscle strength; improved connective tissue strength and integrity, increased bone density, promotion of circulation to enhance soft tissue healing, improvement of muscle recruitment, improved proprioception, and coordination, and increased range of motion are used to promote normal movement patterns. May also include alternative/complementary exercise movement therapy (with oversight of a physician or appropriate healthcare professional).”p.94 to 95
There is some evidence that Iyengar yoga, which avoids back bending,results in improved function and decreased chronic mechanical low back pain for up to 6 months. One quarter of the participants dropped out. Instruction occurred 2 times per week for 24 weeks and was coupled with home exercise. Yoga may be an option for motivated patients. 48 sessions is the maximum expected duration and time to effect is 8.”p.94
Manipulation
“Manipulation: Manipulative Treatment (not therapy) is defined as the therapeutic application of manually guided forces by an operator to improve physiologic function and/or support homeostasis that has been altered by the injury or occupational disease, and has associated clinical significance.
There is good evidence that a combination of exercise and spinal manipulation is more effective than manipulation alone in relieving chronic neck pain, and that these advantages remain for more than one year after the end of treatment. Conversely, there is some evidence that a combination of spinal manipulation and exercise is more effective than exercise alone in reducing pain and improving function of low back pain for one year. There is good evidence that spinal manipulation has a small superiority to other common interventions (standard medical care, physiotherapy, and exercise alone) for chronic low back pain, making it comparable to other commonly accepted interventions for this indication. The decision to refer a patient for spinal manipulation rather than for other treatments should be made on the basis of patient preference and relative safety, not on an expectation of a greater treatment effect. Manipulation may be indicated in patients who have not had an evaluation for manual medicine, or have not progressed adequately in an exercise program. Manipulative treatments may be applied by osteopathic physicians, chiropractors, properly trained physical therapists, properly trained occupational therapists, or properly trained medical doctors. Some popular and useful techniques include, but are not limited to, high velocity, low amplitude (HVLA), muscle energy , strain-counterstrain, a balanced ligamentous tension and myofascial release. Under these different types of manipulation exist many subsets of different techniques that can be described as a) direct- a forceful engagement of a restrictive/pathologic barrier, b) indirect- a gentle/non-forceful disengagement of a restrictive/pathologic barrier, c) the patient actively assists in the treatment and d) the patient relaxing, allowing the practitioner to move and balance the body tissues. When the proper diagnosis is made and coupled with the appropriate technique, manipulation has no contraindications and can be applied to all tissues of the body, including muscles, tendons, ligaments, joints, fascia and viscera. Pre-treatment assessment should be performed as part of each manipulative treatment visit to ensure that the correct diagnosis and correct treatment is employed. Contraindications to HVLA manipulation include joint instability, fractures, severe osteoporosis, infection, metastatic cancer, active inflammatory arthritides, aortic aneurysm, and signs of progressive neurologic deficits. Time to Produce Effect: 4 to 6 treatments. Frequency: 1 to 2 times per week for the first 2 weeks as indicated by the severity of the condition. Treatment may continue at 1 treatment per week for the next 6 weeks. Optimum Duration: 8 weeks. Maximum Duration: 8 weeks. At week 8, patients should be reevaluated. Care beyond 8 weeks may be indicated for certain chronic pain patients in whom manipulation is helpful in improving function, decreasing pain and improving quality of life. In these cases, treatment may be continued at one treatment every other week until the patient has reached MMI and maintenance treatments have been determined. Extended durations of care beyond what is considered “maximum” may be necessary in cases of re-injury, interrupted continuity of care, exacerbation of symptoms, and in those patients with comorbidities. Such care should be re-evaluated and documented on a monthly basis.
Mobilization (Soft Tissue): Is a generally well-accepted treatment. Mtrobilization of soft tissue is the skilled application of muscle energy, strain/counter strain, myofascial release, manual trigger point release, and manual therapy techniques designed to improve or normalize movement patterns through the reduction of soft tissue pain and restrictions. These can be interactive with the patient participating or can be with the patient relaxing and letting the practitioner move the body tissues.
Indications include muscle spasm around a joint, trigger points, adhesions, and neural compression. Mobilization should be accompanied by active therapy. Time to Produce Effect: 4 to 9 treatments. Frequency: Up to 3 times per week. Optimum Duration: 4 to 6 weeks. Maximum Duration: 6 weeks.”p.96 to 98
“Acupuncture
Acupuncture is recommended for chronic pain patients who are trying to increase function and/or decrease medication usage and have an expressed interest in this modality. Credentialed practitioners with experience in evaluation and treatment of chronic pain patients must perform acupuncture evaluations. Indications include joint pain, joint stiffness, soft tissue pain and inflammation, paresthesia, post-surgical pain relief, muscle spasm, and scar tissue pain.
Acupuncture with Electrical Stimulation:
It is indicated to treat chronic pain conditions, radiating pain along a nerve pathway, muscle spasm, inflammation, scar tissue pain, and pain located in multiple sites. There is some evidence that a combination of electrical acustimulation to the wrist combined with neck stretching and strengthening exercises for 30 minutes two times per week for a period of about 4 weeks demonstrates more improvement in chronic neck pain and patient self-confidence in performing functional activities than neck exercises alone for up to one month. Time to Produce Effect: 3 to 6 treatments. Frequency: 1 to 3 times per week. Optimum Duration: 1 to 2 months. Maximum Duration: 15 treatments.”p35 to 36
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