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Modalities should always be considered an adjunct to an active treatment program
in the management of acute low back pain. They should never be used as the sole
method of treatment. The prescribing physician should first be aware of all
indications and contraindications for a prescribed modality and have a clear
understanding of each modality and its level of tissue penetration. The goals
of treatment should be clear to the patient and the treating therapist from
the onset of treatment. Patients are done an injustice when a therapeutic physical
therapy program is modality-intensive as opposed to exercise-based. A poor functional
outcome has been demonstrated in patients treated with a passive, modality-intensive
program compared to those in an exercise-based program. If at all possible,
patients should be instructed in the use of simple modalities at home prior
to their physical therapy sessions and in conjunction with their home exercise
program. Transcutaneous Electrical Nerve Stimulation (TENS)
Transcutaneous electrical
nerve stimulation (TENS) has been used to treat a variety of pain conditions.
Success rates range greatly due to many factors including electrode placement,
chronicity of the problem, and previous treatments. It is generally used in
chronic pain conditions and not indicated in the initial management of acute
low back pain. Documentation of greater than 50% reduction in pain with a treatment
trial may help substantiate its true beneficial effects as opposed to a placebo
response. Electrical Stimulation
High voltage pulsed galvanic stimulation has
been used in acute low back pain to reduce muscle spasm and soft tissue edema
(swelling). It is commonly used despite the lack of hard scientific evidence
for its efficacy. Its effect on muscle spasm and pain is felt to occur by its
counter-irritant effect, effect on nerve conduction, and a reduction in muscle
contractility. Use of electrical stimulation should be limited to the initial
stages of treatment, such as the first week after injury so that patients may
quickly progress to more active treatment, which includes a restoration of range
of motion and strengthening. It may often be combined with ice or heat to enhance
its analgesic effects. Ultrasound
Ultrasound is a deep heating modality that
is most effective in heating tissues of deep joints. It has been found to be
helpful in improving the distensibility of connective tissue, which facilitates
stretching. It is not indicated in acute inflammatory conditions where it may
serve to exacerbate the inflammatory response and typically provides only short-term
benefit when used in isolation. It is perhaps best used to improve limitations
in segmental spinal range of motion following recurrent or chronic low back
pain as an adjunct in facilitating soft tissue mobilization and prolonged stretching
by a skilled manual therapist. The use of ultrasound is contraindicated over
a previous laminectomy or peripheral nerve secondary to alterations in membrane
stability. It should be discontinued as segmental motion is improved with the
patient then moved into an active strengthening program and eventual transference
to an independent home exercise program. Superficial Heat
Superficial heat can
produce heating effects at a depth limited to 1-2cm. Deeper tissues are generally
not heated due to the thermal insulation of subcutaneous fat and the increased
cutaneous blood flow which dissipates heat. It has been found to be helpful
in diminishing pain and decreasing local muscle spasm. Superficial heat, such
as the hydrocolater pack, should be used as an adjunct to facilitate an active
exercise program. It is most often used during the acute phases of treatment
when the reduction of pain and inflammation are the primary goals. If beneficial,
it can be incorporated into the education program and utilized on a home basis
prior to the therapy program. Cryotherapy
Ice packs or cryotherapy are generally
more effective in terms of depth of penetration than other superficial thermal
modalities. Intramuscular temperatures can actually be reduced by 3-7 degrees
C. This is helpful in reducing local metabolism, inflammation, and pain. The
analgesic effects of ice result from a decreased nerve conduction velocity along
pain fibers and a reduction of the muscle spindle activity responsible for mediating
local muscle tone. It is usually most effective in the acute phase of treatment,
though the patient can use it after physical therapy or the home exercise program
to reduce pain and the inflammatory response. It is applied over an area for
15-20 minutes, 3-4 times per day initially and then on an as needed basis. Peripheral
nerve injury and local frostbite secondary to prolonged cryotherapy has been
previously described, emphasizing the need for monitoring of cryotherapy use.
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