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Pain Tolerance

Vol. 15 •Issue 8 • Page 37
Pain Tolerance

How and when to use pain medication for patients during therapy

Anyone who has successfully recuperated from an injury with the aid of physical therapy knows it is not an easy process. PT can be a challenging, demanding and sometimes even painful experience.

In the end, however, those who are able to ignore or overcome the pain to push themselves further experience the most extensive recoveries.

One of the most important jobs of a physical therapist is helping patients manage pain and discomfort brought on by intensive rehabilitation.

"Painkillers can allow patients to complete more activities and participate to a greater level during a physical therapy session," said Lori Evans, PT, of the Texas Back Institute in Plano, TX.

Evans said that pain medication can reduce 7-8 level pain to a 3-4 level, making it considerably easier for the patient to rehabilitate more effectively, at a higher intensity and for longer durations.

"One thing I tell my patients is that if they want me to prescribe painkillers, they're either going to pay for it, or they're going to earn it," said Andre Hu, MD, specialist in physical medicine and rehabilitation.

When To Use Medication

Dr. Hu explained that many of his patients are apprehensive of or even fear the idea of going to physical therapy, because of the pain they're in. "I have to explain to them that it is the pain that's limiting them," he said.

Thus, Dr. Hu wants his patients to "pay" for using the medication by putting it to use in a workout or physical therapy regimen after usage, or "earn" it by completing a therapy session before taking the medication.

Evans agreed that, depending on the patient, their condition and the levels of pain they are experiencing, the best time to use medications can vary. "It can be beneficial to take medication prior to PT, to allow increased tolerance to treatments," she said. "But on the flip side, pain medications may mask pain that the patient is having in response to a treatment."

Often, a trial and error process is recommended to determine what schedule best fits a patient. However, for therapists like Laurie Baer, PT, CWS, who works in burn care, time schedules for medication use are more specific. Patients require medication to be able to tolerate physical therapy to any degree.

Baer, senior staff therapist at Temple University Hospital in Philadelphia, said pain medication for patients is essential within her scope of practice.

"I'd say that [the burn care unit] uses pain medication more than any other area of the hospital," said Baer. "We couldn't get our patients back to a functional level without medications."

Medications help with debridement procedures, which Baer described as "very painful, but necessary" to promote proper healing.

While a patient is hospitalized for burn care, physical therapists usually choose to see him during wound dressing changes, when the levels of pain medication in his system are at their highest. It is at this time that the therapist is most able to push the patient to greater limits and work through a greater range of motion. "If you waited until later to see the patient, you wouldn't accomplish that same range of motion," said Baer.

The same applies once the patient is released from the hospital. Even after discharge, the patient will return three times a week for dressing changes, at which time they also see their physical therapist. At Temple University Hospital, patients are sent home with a prescription for pain medication (the particular brand of medication is a decision made by each individual patient's doctor.) Baer directs her patients to take two pills about an hour before therapy appointments.

"As a professional, you want to look at the underlying reasons for what's causing the pain," Baer conceded. "But in burn care, that's a very straightforward matter. And while their usage won't last forever, medication helps people to get through the periods of worst pain and allows them to move. If they weren't able to move, we'd have an even greater problem with contractures."

Potential Drawbacks

Perhaps more than any other regularly prescribed drug, painkillers carry a rather nasty reputation for their assumed ease of addiction—a reputation Baer believes is undeserved.

"People are always concerned that [they] will become addicted," she admitted. "Certainly, with our population a lot of people come in who have already been down that road."

But in the long run, Baer believes this problem is somewhat overhyped. "From research that I've done, the instance of people becoming addicted to pain medication—when it's given for a medical reason—is very low," she said. "I think in the public's mind, we think it's much higher because of a few high-profile cases of people becoming addicted."

In fact, Christopher Biewer, PT, of Schwab Rehabilitation Center in Chicago, sees the opposite problem. "Patients tend to not effectively use their medicine," he said. "They tend to take it only when they have pain, instead of taking it when their doctor prescribes. That limits some people in therapy, because then they'll come in on certain days, and they're [in excruciating pain]."

Economic concerns and lack of education are the main factors that contribute to the underutilization of pain medication. "Patients tend to self-discharge the medicine," he said. "There's more education that needs to be done in that area."

Perhaps also due to lack of education is the reliance of some patients on alternative, unproven means of pain reduction, such as oils and soaking in Epsom salts.

"There's no study anywhere in the world that said these methods will give you any relief," said Biewer. "I think we as physical therapists need to be a little less concerned with insulting someone's beliefs about these alternative medicines."

Of course, even when patients take the medicine exactly as prescribed, it can lead to problems following PT appointments. "When using medications, patients may be pain free," Evans pointed out. "This can lead to their overloading of the tissues, which causes them to experience an increase in pain later in the day or the next day."

Another important factor is the duration of usage with any type of pain medication. Prolonged usage can reduce the body's productions of its "natural painkiller," endorphins. "Endorphins can be many times more powerful than morphine," said Evans. "It can be more beneficial to teach the patient other modes of controlling pain."

These, she said, include psychophysiological control skills of relaxation, as well as low-impact exercise such as walking or swimming.

Unfortunately, it's nearly impossible to outline a fool-proof plan for usage of pain medication. Much like anything in life, perhaps the best advice to follow, as Dr. Hu suggested, is to do everything in moderation.

"It's best to take medication before therapy, to promote better PT," he said. "If after therapy, your pain isn't that bad, you can reduce the dosage. Pain should naturally decrease as PT progresses."

New Techniques

In light of the obvious number of uncertainties involved with utilizing conventional pain medications for the purposes of physical therapy, it only makes sense to look at some methods of pain management that can be used more for specific purposes of PT.

One such method is the epidural catheter, which is especially effective for knee and shoulder injuries. Such devices are often used immediately after knee reconstruction surgery to help the patient handle the pain.

The catheter is inserted into the affected body part under X-ray guidance, and attached to a pack with local anesthetic. The device can relieve pain to allow therapists to conduct treatment that would otherwise be unbearable for the patient.

"If the therapist is unable to provide PT due to pain, nothing works like epidural," said Donal Kramer, MD, of River Oaks Pain Management in Houston, TX.

Another more temporary solution is a fentanyl transmucosal lozenge, which is used in operating rooms. The lozenge is applied via a swab inside the mouth, where the medicine is transmitted via the mucosa throughout the body in a matter of minutes. This particular medicine is sometimes used to sedate patients during surgery—obviously, for physical therapy purposes, it is used in lesser amounts.

"The main advantage to the lozenge is that by rubbing it on, you can control its dispersal," said Dr. Kramer. "With pills, once they are ingested, you have no control over how much or when the medicine is released."

Dr. Kramer cautioned that the lozenge should be utilized solely for physical therapy, not to cope with daily pain.

While there is no cure-all in the pharmaceutical world to make PT easier for patients, therapists continue to seek and research newer, effective means of helping their patients to cope.

"Some patients have a fear of movement because they are afraid of the possibility of increasing their pain," said Evans. "Pain medicine can be beneficial in helping to decrease those fears."

Rob Senior is on staff at ADVANCE and can be reached at


I recently received a knee transplant, and am undergoing in home PT. While I have made significant progress in most of the exercises, perhaps the most important one, I seem to have become stymied in the flexing department. My therapist has opined that I may have some sort of psychological resistance to this, not allowing my pain level to pass a certain point. Could there be anything to this? If so, could anyone suggest a way for me to "relax", so to speak, and allow the healing, however painful, to proceed? This is my second knee replacement, and although the 1st time around this exercise was just as excruciating, I managed to get through it. Any and all recommendations on how to get past this hurdle would be deeply appreciated. Many thanks for your time.

Chris Evans,  retiredDecember 09, 2016


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