Oct 22, 2017Making Gains on Pain: The evolution of pain management
During the first lecture of her “Therapeutic Interventions” course at the University of Texas-Arlington, Cindy Trowbridge, PhD, ATC, LAT, CSCS, has delivered a critical piece of wisdom to a classroom full of future athletic trainers. “There are no protocols, there are only patients,” she tells them.
With an abundance of methods available for managing pain in competitive athletes — ranging from old-school hot and cold therapy to state-of-the-art digital technology — it’s easy for athletic trainers to simply choose a favorite and stick with it. That’s a trap Trowbridge, Associate Professor of Kinesiology at UTA, finds is all too common in the profession.
“No two injuries are the same,” she says. “We just can’t blanket-treat people.”
“My absolute favorite technique is good clinical reasoning,” adds David Ruiz, MS, ATC, LAT, CSCS, LMT, who has been an athletic trainer at the high school and college levels. “The ability to reason through a patient’s problems and select the appropriate treatment is always going to be better than relying on any one technology or specific technique.”
Fortunately for practitioners, pain management applications have advanced at a rapid pace, providing plenty of options to choose from. We took a look at the evolution of managing pain in today’s athletes.
Hot & cold
For decades, cold therapy — an enduring cornerstone of pain management — meant using ice packs or immersion in an ice bath. Similarly, heat therapy was warming a bag or bottle and applying it to sore muscles. Both techniques resulted in limited, temporary relief (and frostbite or minor burns, if the athlete or practitioner wasn’t careful).
“Recovery does not just include being pain-free. It’s about an improved quality of life.”
Today, those old-school practices are supplemented by newer products that provide easier access to cold or heat. Apparel items now come equipped with compact gel-based packets or patches, some of which retain a designated temperature for hours.
Theories on the use of cold and hot therapies have changed over the years, too, with new research claiming that cold therapy is not as physiologically effective as once thought — a contention some in the field dispute. “I’m still using cold treatment, because I have received a lot of pain relief from it personally,” says Maria Hutsick, MS, ATC, LAT, CSCS, Head Athletic Trainer at Medfield (Mass.) High School. “I’m going to let the researchers fight this one out in the medical journals.”
Arguably the biggest change in cold therapy began with the introduction of portable products that combined ice and compression therapy. Designed to contain swelling and minimize pain, these units contain pouch-like devices filled with cold water that deliver cold therapy and pneumatic compression through wraps specially designed for various body parts, such as the arm or knee. This approach eliminated melted ice and soggy plastic bags while providing athletes with more comfortable — and some say more effective — treatment.
The concept of using compression to manage athletes’ pain did not even exist 25 years ago. The idea that someone could wrap a defensive lineman’s knee, adjust a few settings, and push a button to generate relief via a machine set on a sideline bench might as well have been something out of a sports-themed science-fiction story. Compression was then an exceptionally specialized treatment that required bulky equipment, was difficult for practitioners to effectively apply, and was uncomfortable for athletes. But today’s wearable compression clothing and braces not only relieve pain, they also help prevent injuries, putting the compression market into the mainstream.
In fact, the recent movement toward self-care by athletes, especially weekend warriors, has driven the introduction of compression and other pain management treatments that users can apply themselves. This has resulted in athletes better understanding their bodies and how to treat their own injuries, but has the negative of removing the medical professional from the equation.
“Treatment needs to be repeated in order to be successful,” Trowbridge says. “And there is less likelihood of that happening at home. Recovery does not just include being pain-free. It’s about an improved quality of life.”
Once upon a time, topicals were available only in cream form, and they would burn or sting when coming into contact with skin. Today, they have expanded to include sprays, sticks, foams, roll-ons, and patches.
In fact, transdermal patches that deliver a specific, time-release dosage of medication through the skin have become increasingly popular. Some of them contain new forms of all-natural topicals that utilize alternative medicine to ease muscle strain after an acute injury or surgical procedure.
While topicals have been highlighted in the mainstream media and athletes are increasingly asking for them, there has not been significant research on the products. For now, most athletic trainers are carefully using topicals, while keeping an eye out for new studies.
Electro-stim & laser therapy
Electrical muscle stimulation, or electro-stim, has greatly evolved during the past 25 years, with units becoming lighter, portable, and much less expensive. Electro-stim patches are now even sold for home use.
Although it has been used to activate muscle movement for at least the past two centuries, the idea of incorporating electrical stimulation into the treatment of elite athletes didn’t take root until the 1960s. Even then, conflicting studies and mixed results led to a poor understanding of the modality.
By the 1990s, though, college and university athletic training programs were teaching electro-stim as a common modality to manage pain, sometimes used in conjunction with medication injected into the pad. As electro-stim became more convenient, it became a popular way to inhibit pain and increase blood flow, especially for time-crunched athletic trainers treating multiple athletes at the same time.
However, some practitioners don’t like using electrodes or gels, including Timothy Demchak, PhD, ATC, LAT, Associate Professor of Applied Medicine and Rehabilitation at Indiana State University. He is also the Founder and Director of the Orthopedic Rehabilitation Center in Terre Haute, Ind., which offers free rehab services — so reusable materials are important for continued operation. When the U.S. Food and Drug Administration approved the use of laser therapy in the United States in 2002, Demchak became one of its first proponents in the athletic training world.
Low-level laser therapy can be used to treat inflammation, provides deep-tissue therapy, and accelerates pain relief, Demchak says. He has particularly noticed significant improvements in athletes suffering from fibromyalgia, and in some cases he has loaned them hand-held lasers they can use once a day at home to eliminate pain in as little as four days.
“I had no idea I would be treating patients this way,” Demchak says. “The results I’m seeing are great. I often wonder why everybody is not using this treatment.”
He feels skepticism of low-level laser therapy for athletes has been driven by misinformation. However, its use is growing among professional sports teams. Research also suggests that laser therapy can lower the risk of arthritis developing as a result of sports injuries. As technology continues to improve, laser therapy could emerge as a game-changer in athletic rehabilitation.
An even newer modality combines electro-stim and low-level laser therapy. It involves a “deep oscillation machine” that penetrates a patient’s tissue with minimal pressure, allowing for accelerated regeneration of tissues. Electrostatic waves create a kneading effect deep within damaged tissues to relax muscles, alleviate pain, reduce swelling, and restore flexibility and blood supply to the affected area.
Additionally, the recent development of portable ultrasound therapy machines has made it easier for athletes to rely on this type of pain management without requiring access to a clinician’s equipment. A battery-operated and easy-to-wear offshoot of low-intensity therapeutic ultrasound, it can be effective in decreasing pain in necks, backs, elbows, knees, and shoulders.
Another development to emerge over the past two and a half decades is a return to the ancient art of deep-tissue massage and manual therapy. Hutsick is a big proponent of this back-to-basics approach.
“When I was at Boston University, we went to all manual therapy, because you can get so much more accomplished,” she says. “And the athletes appreciated that it allows for more one-on-one time.”
With no equipment needed other than a high-low exam table, hands-on therapy requires a greater degree of commitment from the athletic trainer. “You’re really using your body to physically treat people,” Hutsick says, adding that overseas practitioners have been engaging in manual therapy “much longer than we have in the United States.”
In addition, more and more athletic trainers are finding good results with very specific manual therapy methods. Instrument-assisted soft-tissue mobilization, which uses stainless-steel instruments to detect and treat soft tissue fibrosis or chronic inflammation, has a growing following. Also gaining in popularity is Active Release Technique (ART), a soft-tissue mobilization technique used to treat muscles, tendons, ligaments, fascia, and nerves.
A bit more controversial is dry needling, the practice of using needles to relieve muscle pain that has its origins in Chinese and Japanese medicine. Ruiz says the technique is still evolving, and clear indicators need to be identified for when dry needling is an appropriate modality. “Anytime you’re dealing with needles, you have to be sure of yourself,” he says. “Plus, I might already be using a different modality that’s just as effective.”
In the realm of alternative therapies, chiropractic care has also gained ground with athletes. “In the past, chiropractors have gotten a lot of bad publicity,” Hutsick says, referring to largely unsubstantiated claims about the inefficacy of chiropractic care. “I believe in chiropractic, especially if the injury needs more skills to treat than I have.”
An app for that?
At least one modality for managing athletes’ pain involves no hands-on techniques, no plug-in technology, and no ice or heat. Rather, the primary piece of equipment is a late-model smartphone or personal tablet.
Using the device’s video technology, an athletic trainer can film an injured athlete’s movements and then perform a biomechanical analysis using an app. The newest ones allow users to capture up to 240 frames per second, play the footage back in slow motion, zoom in on details, and draw lines, squares, circles, and arrows on the screen.
“It can really guide your clinical examination,” says Ruiz. “With these apps and other functional movement screening approaches, I can get a great baseline, and then use it to find the problem.
“People incorrectly believe we just have to get the athlete through the season by any means of rehab possible, and then find and treat the source in the offseason,” he continues. “Now we can get to the source during the season by using this technology.”
None of the pain management modalities to emerge since the first issue of Training & Conditioning appeared in 1990 have made time-tested ice packs and creams obsolete. In fact, the widespread acceptance of multiple modalities — both old and new — suggests that the perfect one has yet to be developed. In fact, it may never be developed. “No treatment is 100% appropriate all of the time,” Ruiz says, stressing that the loyalties of athletic trainers should seldom rest with a single approach or product.
While everyone has his or her preferences, an open-minded outlook toward pain management, including keeping up with current research and technological advancements, is the way to go. The ever-evolving realm of treating competitive athletes’ injuries ensures that plenty of options will be available for practitioners and patients.
“Just because electro-stim worked for you and your patient doesn’t mean it will work for me and my patient,” Trowbridge says. “But as long as modalities are being used in smart ways, and you are being a prudent clinician using a particular device, I don’t think there is one right or wrong path.