PAIN MANAGEMENT GUIDE
CREATED BY THE NFLPA PAIN MANAGEMENT COMMITTEE:
AMBER CARGILL, PSY.D
DAVID DRIVER, M.D.
BETSEY GILBERTSON
KENT HUTCHISON, PHD
GRAEME LAURISTON, PT
HIRAL MASTER, PHD
DAVID NAGEL, M.D.
SUSAN MURPHY, SCD
SHARI S. THOMAS, M.D.
THE BEST APPROACH TO TREATING PAIN
is choosing a combination of options provided by pros who collaborate on your care.
Evaluate the risks and benefits of treatments and create a personal plan to maximize your performance through effective pain management.
MANUAL THERAPY
INSTRUMENT ASSISTED SOFT TISSUE MOBILIZATION
04 13 05 14 06 15 07 16 08 17 09 18 10 19 11 20 12 21
ACETAMINOPHEN
NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS)
MYOFASCIAL CUPPING
BLOOD FLOW RESTRICTION
INTERMITTENT PNEUMATIC COMPRESSION THERAPY
VIBRATION THERAPY
UN-WEIGHTED TREADMILLS
ELECTRICAL STIMULATION
HYPERBARIC CHAMBERS
PHOTOBIOMODULATION
WHOLE BODY CRYOTHERAPY
EXTRACORPOREAL SHOCK WAVE
SAUNA
LOW LEVEL LASER THERAPY (CLASS I, II, III)
THERMAL LASER THERAPY (CLASS IV)
SENSORY DEPRIVATION TANK
HIVAMAT
SHIFTWAVE
ARP WAVE
HYPOXIA MASK
ACUPRESSURE
ACUPUNCTURE
MASSAGE
GLUCOCORTICOIDS (CORTISONE RELATED MEDICATIONS(ORAL))
OPIODS
TRICYCLIC/TETRACYCLIC ANTIDEPRESSANTS (TCAS)
SERATONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs)
ANTIEPILECTIC
CAPSAICIN
CAMPHOR
KETOROLAC (TORADOL)
TRIGGER POINT INJECTION
RADIO-FREQUENCY NEURO-ABLATION (RFA)
PROLOTHERAPY
PLATELET-RICH PLASMA (PRP)
BONE MARROW ASPIRATE CONCENTRATE (BMC OR BMAC®)
INTERVENTIONS FOR SLEEP
CANNABIS
COGNITIVE BEHAVIORAL THERAPY (CBT)
MINDFULNESS BASED STRSS REDUCTION (MBSR)
ACCEPTANCE AND COMMITMENT THERAPY (ACT)
OPERANT-BEHAVIORAL THERAPY
IDEAS FOR PAIN MANAGEMENT
MANUAL THERAPY INSTRUMENT ASSISTED SOFT TISSUE MOBILIZATION
Manual therapy is the skilled application of passive movement to a joint either within (‘mobilisation’) or beyond (‘manipulation’) its active range of movement. Effects can be physiological, biomechanical/physical and psychological.
Techniques include oscillatory techniques, high velocity low amplitude thrust techniques, sustained stretching and muscle energy techniques. Can be applied to joints, muscles or nerves.
Aims of treatment are pain reduction, increasing range and quality of joint movement, improving nerve mobility, increasing muscle length and restoring normal function.
4 Categories: MTI (high-velocity low-amplitude manipulation), MT2 (mobilization and/or softtissue-techniques), MT3 (combination of MT1 & MT2), and MT4 (mobilization with movement).
Performed by a range of medical professionals, including certifi ed athletic trainers, physical therapists, chiropractors, massage therapists, and osteopathic doctors.
Safe and effective; can be used for pain modulation and soft tissue manipulation.
Utilizing an instrument, the clinician will apply the recommended pressure to the area and begin scraping across the surface of the skin.
Frequencies and pressure depend on the goals of the clinician as part of a skilled rehabilitation program.
MYOFASCIAL CUPPING BLOOD FLOW RESTRICTION
The cup is applied to the skin and with a manual vacuum, air is removed from inside the cup creating the suction to the skin. This vacuum seal then promotes blood flow to the area.
Application can vary as some clinicians will leave the cup on the affected area for a short amount of time, manually moving the cup across the surface of your skin, creating manipulation of the connective tissue.
Many therapeutic interventions are compressive in nature, but cupping is one of the only true decompressive interventions.
Utilized for many conditions, most commonly used for tight/sore musculature alongside a skilled rehabilitation program.
Blood Flow Restriction or “BFR” is when external pressure is placed on a proximal limb to promote blood pooling in capillary beds distal to the tourniquet.
Studies have shown that muscle hypertrophic adaptations, (release of growth hormones, insulin growth factors) can be induced with much lower intensities (20-30% of 1RM).
INTERMITTENT PNEUMATIC COMPRESSION THERAPY
Requires an external unit alongside sleeves that cover the affected limb(s).
Once the sleeves are in place, they are connected to the unit that will sequentially provide compression starting distally and proximally through the sleeve by pumping air into each pocket or segment along the sleeve.
As the air pressure increases to its max, the system will move up the chain creating a “milking” effect of the limb.
VIBRATION THERAPY
There is clear evidence that vibration therapy stimulates the central nervous system to assist with decreasing pain and improving the perception of improved range of motion.
Full body vibration therapy has been proven to have a hormonal response, but both full body and local vibration therapies still need further research to fully understand the mechanisms behind the results.
UN-WEIGHTED TREADMILLS
The biggest benefit and use for an unweighted treadmill is the ability to remove the amount of body weight from weight bearing activities.
This allows athletes recovering from post-surgical or lower body injuries to start rehabilitation from non-weight bearing to weight bearing activities.
ELECTRICAL STIMULATION HYPERBARIC CHAMBERS
Electrodes are placed on the patient’s skin and connected to the unit that delivers a specific current to the pads.
The two common uses for electrical stimulation are for pain modulation or for muscle re-education, depending on the frequency used.
Two modes of delivery: a single-person cylindrical tube in which you lay or a small room that can hold 3-4 clients.
The tube or room is securely pressurized, increasing the atmospheric pressure, allowing your lungs to capture more oxygen.
Once the oxygen is in your system, it is carried through your body via blood, allowing your body to release certain growth factors and stem cells to h elp fight infections and promote healing.
PHOTOBIOMODULATION
Treatment can be applied using variety of devices to include panels; handled devices and beds. Treatments have been fond to be effective for improving sleep, increasing endurance, improving muscle recovery after exercise, reducing pain and reducing inflammatory markers. As a relatively new modality, further rese arch is needed to identify optimal dosage and delivery for specific outcomes.
Two forms of treatment:
Standing solo in a cylinder chamber with your head exposed
In a small room that holds up to 4 adults
In treatment, your body is exposed to extreme low )-100*C to -300*C) temperatures.
WHOLE BODY CRYOTHERAPY EXTRACORPOREAL SHOCK WAVE
Treatment time lasts 2-4 minutes and has been proven through recent research to reduce pain in injured individuals as well as reduce inflammation and markers that indicated cell damage.
Invasive therapy that utilizes high energy pulses or “shock waves” to the targeted area of the body.
These pulses can vary in intensity based on several unique factors of the patient’s presentation.
The pulses create a “popping”, “clicking”, and/or “tapping” sensation on the surface of the skin, but the energy of the pulse can travel deep into the body.
SAUNA
Different forms of sauna exist. Dry (sometimes called Finnish) wet (sometimes called Turkish saunas) or infrared. Although similar in mechanism, there is less research on wet and infrared sauna and performance compared to dry sauna. Dry saunas are typically applied at 185-210 degrees Fahrenheit, with 10-20% humidity for a period of 20-30min. Users should begin at the cooler, and shorter ends of those ranges, and progress as toler ated. Dry saunas can significantly improve recovery from metabolic (cardiovascular) stress. Dry saunas have been shown to and be beneficial at improving a wider range of markers associated with aging.
LOW LEVEL LASER THERAPY (CLASS I, II, III)
Low Level Laser Therapy (LLLT) is a modality using low level laser or light emitting diodes across the surface of the skin.
This near infrared light is used to reduce inflammation and pain, both acute and chronic in nature, as well as promote soft tissue healing and wound care.
THERMAL
LASER
THERAPY (CLASS IV)
High Power Laser Therapy that emanates triple wavelength radiations at the same time, working 8/10 cm deep, improving efficacy.
These devices are referred to as “class IV” reaching 7.500 mW power following previous “class III” or low-level laser that had a limited power up to 500 mW.
SENSORY DEPRIVATION TANK
Sensory Deprivation Tanks or Flotation-REST (restricted environmental stimulation techniques) tanks are tanks filled with about 1 foot of water that has a high concentration of salt.
This high concentration makes it very buoyant in which the patient can float easily in the tank.
These tanks are found in soundproof and light proof rooms to restrict all external sensations once fully relaxed.
Treatment starts lying on your back floating in a quiet dark room, allowing the body and mind to simply reset from all the external stress on the body.
HIVAMAT
Hivamat deep oscillation therapy is an approved modality by the FDA for use with muscle relaxation, increasing circulation and pain relief.
This modality has two methods of delivery, either by wand or the clinician/therapist’s hands.
An electrode is placed on clean, dry skin on both the clinician and the athlete and the clinician wears gloves with the use of baby powder to massage the treatment area.
SHIFTWAVE
Pulsed pressure waves at varying patterns and intensities that have shown a positive impact on heart rate variability. This product can be used pre game/practice or post game/practice depending on the variation of the pulsed pressure wave pattern. This product is in early stages and more studies remain needed.
ARP WAVE HYPOXIA MASK
The ARP Wave (Accelerated Recovery Performance) is a system that uses bioelectrical current, simultaneously with active range of motion/exercises to speed up the body’s natural healing ability.
ARP Wave is said to have positive cellular effects of direct current electrical fields on bone and tissue healing.
Mask covers the nose and mouth with different sized openings and flux valves.
The openings and flux valves can be adjusted to increase the resistance of respiration, making it more difficult to breathe while wearing the mask.
The goal of these masks is to mimic high elevation training which is proven to boost the production of red blood cells.
ACUPRESSURE
Often described as acupuncture without the needles
Used for various reasons: pain relief, improving fatigue and sleep disturbances.
Acupressure can be applied by a trained practitioner or self-administered.
ACUPUNCTURE
There are 117 conditions for which there is some evidence of efficacy for the use of acupuncture including various types of pain.
A typical treatment involves the placement of needles in specific acupoints.
There are various combinations of needles used specific to the diagnosis being treated and the school of acupuncture followed by the therapist.
The needles may be stimulated manually, herbally, thermally, or electrically.
A typical treatment may last from 20 - 60 minutes
MASSAGE
Used as a treatment for injuries to promote healing in damaged tissues and for chronic pain reduction.
Used to reduce stress, improve mood and increase overall well-being.
DRY NEEDLING
A solid filiform needle is inserted into the skin, typicalling into trigger points, to treat musculoskeletal and myofascial dysfunctions as well as pain modulation.
Two commonly used techniques are inserting the needle and leaving it for a set period of time, or inserting and removing the needle in a continuous fast motion called pistoning.
ACETAMINOPHEN NON-STEROIDAL
Over-the-counter analgesic.
First line, primary analgesic for mild to moderate pain.
Frequently used as an adjunct with opioids for moderate to severe pain.
Can be used safely and synergistically with Non-Steroidal Anti-Inflammatory Drugs (NSAID’s) with the combination providing greater analgesia than either alone.
Present in combination with opioids in medications such as Percocet and Vicodin.
ANTI-INFLAMMATORY DRUGS (NSAIDS)
Most commonly administered medications for pain and inflammation.
Include non-prescription and prescription medications.
Drug of choice for short term management of acute nociceptive and/or inflammatory pain.
The evidence for their use in chronic and/or neuropathic pain is limited.
GLUCOCORTICOIDS
(CORTISONE RELATED MEDICATIONS (ORAL))
Effect is to decrease the inflammatory response to injury or other inflammatory process
When injected, they also decrease the sensitivity of the pain nerves (c-fibers)
Not performance enhancing steroids
Takes several days for them to have an effect
Not analgesic by themselves
Rarely used for more than three weeks at a time
OPIODS
Pain relief.
Should only be used as part of a comprehensive, integrative, physician-supervised pain management program.
At the very least, should be combined with a physical modality (heat/cold/e-stim/other) and a restorative modality (stretching, strengthening, proprioceptive training).
Because of risk of addiction, a family member should be included in the treatment team.
TRICYCLIC/TETRACYCLIC ANTIDEPRESSANTS (TCAS)
Pain relief, depression and anxiety
Should only be used as part of a comprehensive, integrative, physician-supervised pain management program
At the very least, should be combined with a physical modality (heat/cold/e-stim/other) and a restorative modality (stretching, strengthening, proprioceptive training)
Long term use is generally considered safe and non-habit forming
SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS
(SNRIS)
Neuropathic pain, depression, anxiety
Onset of action, once adequately dosed, is 1-4 weeks, with peak efficacy being achieved after 6-8 weeks
Best suited for the management of chronic pain
Long term use is generally considered safe and non-habit forming
ANTIEPILEPTIC
(AEDS)
Neuropathic pain, migraines, restless leg syndrome, seizures, depression, bipolar disorder, anger/impulse control issues
Peak efficacy achieved after 6-8 weeks of adequate dosing
Best suited for the management of chronic pain
Long term use is generally considered safe and non-habit forming
CAPSAICIN
Pain treatment
Derivative of chili peppers
Onset of action is immediate, making this a good option for the treatment of acute muscular and neuropathic pain.
Can have long lasting effects, less risks for drug interactions, and lower risk for systemic side effects.
CAMPHOR
Pain
Derivative of the Camphor Laurel, a large evergreen tree.
Onset of action is immediate, and it has antibacterial, anti-fungal, and anti-inflammatory properties making this a good option for the treatment of acute topical pain
KETOROLAC
(TORADOL)
Pain
Does not cause respiratory depression or cognitive side effects as opioids may
Should only be used for severe, acute pain- Should never be used to prevent pain (prophylactically).
TRIGGER POINT INJECTION
TPI is used to treat myofascial pain, which is characterized by a tender tight band in a muscle. These may be due to primary injury in a muscle or secondary activation by a structural (bone, joint, ligament, internal organ) injury.
A fine gauge needle is inserted into the trigger point and a small amount of local anesthetic or saline is inserted. Rarely, cortisone may be injected.
RADIO-FREQUENCY NEURO-ABLATION (RFA)
Used for a variety of medical conditions, primarily in pain management for specific types of back pain.
More recently, uses have been expanded to other structures such as the knee.
RFA involves the deliberate destruction of the sensory nerve to the painful structure using the heat generated from medium frequency alternating current.
While it is a popular procedure in pain management clinics, the evidence remains contradictory.
PROLOTHERAPY
The procedure is used to treat refractory joint, ligament, and tendon injury.
It is thought that by injecting an irritant, the body’s inflammatory system can be better mobilized to heal the injured tissue.
All uses of the procedure are considered off-label.
PLATELET-RICH PLASMA
(PRP)
Venous blood is obtained via routine blood draw and spun down in a centrifuge to concentrate and isolate platelets.
The concentrated platelet product is then injected into the affected area (joint, tendon, ligament, muscle) to promote healing and decrease inflammation and pain.
BONE MARROW ASPIRATE CONCENTRATE
(BMC OR BMAC®)
BMC is obtained by collecting bone marrow from the bone marrow cavity most commonly in the lower back at the posterior pelvis.
The bone marrow is then spun down in a centrifuge to concentrate stem cells and progenitor cells.
The concentrated product is referred to as BMC which is then injected into the area of interest (joint, tendon, ligament, muscle) to promote healing and decrease inflammation and pain.
INTERVENTIONS FOR SLEEP CANNABIS
Cognitive Behavioral Therapy for Insomnia (CBT-I)
Studies have shown that CBT-I can lead to long-term resolution of a variety of sleep issues
Over the counter medications (Melatonin)
Sedative Hypnotics
Antidepressants
Medication interventions are intended for short term use and should only be used under the supervision of a physician
Treatment of acute and chronic pain
Primarily based on a pharmaceutical plant-derived oral preparation with an equal amount of CBD and THC
Not approved by the FDA, with the exception of four products: Marinol, Syndros, Cesamet and Epidiolex.
COGNITIVE BEHAVIORAL THERAPY
(CBT)
Chronic Pain – has been shown to reduce subjective pain by as much as 25%
Chronic migraines, complex regional pain syndromes, arthritis, sleep disorders, and spinal cord injury
Other uses include stuttering, coping with stressful life situations/grief or loss/medical illnesses and injuries, pathological gambling, and smoking cessation
Time-limited (e.g. 12-16 weeks)
MINDFULNESS BASED STRESS REDUCTION
(MBSR)
Chronic pain, headaches, lower back pain, arthritis and insomnia
Reduces the physiological effects of stress, pain or illness
Improve mind and body awareness
Gains have been shown to last up to 4 years after the intervention
ACCEPTANCE AND COMMITMENT THERAPY
(ACT)
Musculoskeletal pain
Two main objectives: 1) training acceptance of problematic, unhelpful thoughts and feelings that cannot and perhaps need not be controlled, and 2) commitment and action toward living a life due to chosen values
OPERANT-BEHAVIORAL THERAPY
Chronic pain, gambling, complex regional pain syndromes, lower back pain
Goal is to correct maladaptive behavioral responses to pain that develop through contingent relief from pain or pain-related fear
Positive side effects on pain experience, mood, negative cognitive appraisals and functioning
PHOTOBIOMODULATION CANNABIS
Treatment can be applied using variety of devices to include panels; handled devices and beds. Treatments have been fond to be effective for improving sleep, increasing endurance, improving muscle recovery after exercise, reducing pain and reducing inflammatory markers.
As a relatively new modality, further research is needed to identify optimal dosage and delivery for specific outcomes.
Treatment of acute and chronic pain
Primarily based on a pharmaceutical plant-derived oral preparation with an equal amount of CBD and THC
Not approved by the FDA, with the exception of four products: Marinol, Syndros, Cesamet and Epidiolex.
COGNITIVE BEHAVIORAL THERAPY
(CBT)
Chronic Pain – has been shown to reduce subjective pain by as much as 25%
Chronic migraines, complex regional pain syndromes, arthritis, sleep disorders, and spinal cord injury
Other uses include stuttering, coping with stressful life situations/grief or loss/medical illnesses and injuries, pathological gambling, and smoking cessation
Time-limited (e.g. 12-16 weeks)
IDEAS FOR PAIN MANAGEMENT
