Zeroing In on Treatment Modalities

By Dimitrios Kostopoulos, DPT, MD, PhD, DSc, ECS

It is a well-established fact that the use of opioid medications for the treatment of pain has become an epidemic in the United States. Still, in some situations, when dosed appropriately, prescription opioids are an appropriate part of medical treatment. However, the Centers for Disease Control and Prevention (CDC) is urging healthcare providers to reduce the use of opioids in favor of safe alternatives like physical therapy.¹

Consistent with these guidelines, the American Physical Therapy Association (APTA) launched a national campaign to raise awareness about the risks of opioids and the safe alternative of physical therapy for long-term pain management as part of its #ChoosePT campaign.²

My position is in total agreement with the CDC and APTA’s position on the opioid epidemic and the need for more effective noninvasive and non-pharmacological methods of treatment. At the same time, there is a challenge in that utilizing only physical examination during physical therapy evaluations without diagnostic testing does not always provide the most effective treatment. In short, it may not fully diagnose the problem or may miss pathologies that lead to ineffective treatment of pain.

Fortunately, today that is changing rapidly as physical therapists are increasingly bringing diagnostic testing into the clinic to troubleshoot issues with challenging patients quickly and accurately. This leads to better outcomes, with patients experiencing faster, more effective results. Among the tests that physical therapists can be trained on include electromyography (EMG) nerve conduction testing, musculoskeletal and neuro ultrasound, vestibular testing to treat patients with vertigo and balance problems, and Evoked Potential tests.

[sidebar float=”right” width=”250″]Product Resources

The following companies provide products for pain management:

Accelerated Care Plus
www.acplus.com

Amrex Electrotherapy Equipment
www.amrexusa.com

Ari-Med Pharmaceuticals
www.ari-med.com

Battle Creek Equipment Company
www.battlecreekequipment.com

Dynatronics Corp
www.dynatronics.com

Everyway4all
www.everyway4all.com

JTECH Medical
www.jtechmedical.com

LightForce Therapy Lasers by LiteCure LLC
www.litecure.com

Mettler Electronics
www.mettlerelectronics.com

OPTP
www.optp.com

Parker Laboratories
www.parkerlabs.com

PHS Medical by Pivotal Health Solutions
www.phsmedicalsolutions.com

Roscoe Medical/Compass Health Brands
www.roscoemedical.com

Sore No More
www.sorenomore.com

Southwest Technologies
www.elastogel.com[/sidebar]

EMG Testing

EMG/NCS testing is one of the most reliable diagnostic tools for many dysfunctions of the Neuromuscular System. An EMG measures the electrical activity of muscles at rest and during contraction. Nerve Conduction Studies (NCS) measure the health of the nerves. Measuring the electrical activity in muscles and nerves can help identify diseases that damage muscle tissue (such as myopathy, radiculopathy, and muscular dystrophy) or nerves (such as amyotrophic lateral sclerosis or peripheral neuropathies).

For symptoms such as numbness, weakness, or tingling in an arm or leg, or conditions like sciatica and carpal tunnel syndrome, an EMG/NCS is a way to assess muscle and nerve function and is often used with other tests such as MRI and CT scan.

Physical therapists have been able to perform EMG and nerve conduction tests for more than 45 years. In 1978, the APTA established a specialty program through the American Board of Physical Therapist Specialties for certification in clinical electrophysiology.

Musculoskeletal Ultrasound

Musculoskeletal Ultrasound (MSKUS) imaging uses sound waves to produce pictures of muscles, tendons, ligaments, and joints throughout the body. It is used to help diagnose sprains, strains, tears, and other soft tissue conditions and to guide therapeutic procedures. Diagnostic ultrasound is a safe and noninvasive test that can provide real-time imaging, allowing for examinations of structures at rest and in motion. As a result, utilization of this diagnostic tool is rapidly becoming the standard of care for visualizing the musculoskeletal anatomy and evaluating and managing joint tissue disorders.

Both the EMG and MSKUS tests are proven to markedly increase the sensitivity and specificity of various physical examination tests used by physical therapists, including the Thenar atrophy, Tinel sign, and Phalen sign for carpal tunnel syndrome³; Neer and Hawkins-Kennedy tests for rotator cuff tears^4,5; Tinel sign, elbow flexion, and pressure provocation for cubital tunnel syndrome^6,7; and distraction and Spurling’s tests for Cervical radiculopathy.^8-10

Without this type of diagnostic testing, pain conditions may be misdiagnosed.

For example, carpal tunnel syndrome with a combined cervical radiculopathy can be misdiagnosed as a cervical radiculopathy alone. So you may be treating a patient for a cervical radiculopathy while the patient may be having an underlying condition of a median nerve neuropathy or an ulnar neuropathy. Sometimes a lumbar radiculopathy can be misdiagnosed as a tibial or peroneal neuropathy.

Pain Management Modalities for treating Acute and Chronic Pain

There are many great treatment modalities that can help in both acute and chronic pain, including, for example, in acute pain TENS units and other electrical stimulation can be rather effective. Providers have several sources from which to find these technologies. One source is Salt Lake City-based Dynatronics, which offers the Dynatron Solaris Plus 708, a device that has three channels of independent treatment setups, including ultrasound, e-stim, and tri-wave light. It is designed with a touchpad that allows the user to move the center of interference to the pain site. Another combination unit is the SoleoSonoStim from Zimmer MedizinSystems, Irvine, Calif.

Therapeutic ultrasound is another modality in the PT toolkit that can be used to manage pain. This technology is used with an ultrasound gel that is applied to the skin. One option for this type of gel is Aquasonic Clear ultrasound gel provided by Parker Labs, Fairfield, NJ, formulated to be acoustically correct for a broad range of frequencies, as well as being water soluble, hypoallergenic, baceriostatic, and non-irritating.

Also, the new technology of Class 4 therapeutic laser in combination with manual physical therapy can help in the treatment of both acute and chronic pain conditions. The clinical market has several sources for this technology as well, including the EXPi Class 4 solid state laser from LightForce Therapy Lasers by Litecure LLC, Newark, Del, which considers patient-specific conditions to help optimize treatment. The line of Apollo Class 4 Cold Lasers from Pivotal Health Solutions, Watertown, SD, is another device in this category, and is available as a desktop or portable model.

Acute and chronic pain symptoms, which are common among PT clientele, can also be treated by combining manual therapy with hot and cold therapy or topical analgesics. These modalities can provide convenient and affordable tools for treating pain in the clinic or for client use at home. In cases where hot and cold therapy is appropriate, the Thermophore and Ice It! product lines from Battle Creek Equipment, Fremont, Ind, offer a wide range of heat packs and cold wraps in varying sizes; some are available in joint-specific designs to fit the contours of the user’s body. In cases where a topical analgesic is appropriate for the temporary relief of pain symptoms, several manufactures provide these products to the PT marketplace. One is Sore No More, from Moab, Utah-headquartered Sore No More, which is formulated with natural plant extracts in addition to menthol, capsaicin, and witch hazel. Flexall, from Ari-Med Pharmaceuticals, is another topical product available to PTs, and is available with concentrations of 7% menthol and 16% menthol. Both Sore No More and Flexall are available in sizes as small as 2 ounces or jugs up to 7 pounds (Flexall) and 1 gallon (Sore No More).

Naturally, for many of these localized treatments to be successful, they must be applied to the source of the pain. This can be an issue, if patients have referred pain in the arm or a leg that is not necessarily where the problem is. Pain can be referred distally in the body by the injury or entrapment of a proximal neural structure, or referred pain can also be the result of myofascial trigger points.

Diagnostic testing allows for the accurate identification of the precise location of the problem, whether distal or proximal.

In addition to its use for diagnosis, musculoskeletal ultrasound can also be used for the treatment of pain and musculoskeletal dysfunction. MSKUS can, for example, guide neural mobilization techniques as well as identify proper muscle recruitment. In states where dry needling is allowed, it can be used to guide the needle to the target tissue, including ligaments.

Bringing Diagnostic Imaging Into the PT Clinic

If there is a barrier to bringing diagnostic testing into the clinic, it is the amount of time and energy required before revenue can be generated. EMG training, when done in a traditional educational setting, can take between 1.5 to 3 years before the physical therapist can conduct the tests on patients.

As a result, training programs now exist that reduce the learning curve and speed the time to reimbursement. Programs like Hands-On Diagnostics help physical therapy practices establish in-house diagnostic services for these and other tests. The national franchise organization is in 18 states with over 115 physical therapy facilities already participating in the program.

The program is supported by live and virtual mentorships with board-certified experts that allow the physical therapist to be able to perform these tests and get reimbursed almost immediately.

The ultimate goal is to provide a clear path for therapists to achieve board certification in clinical electrophysiology testing and certification in musculoskeletal ultrasound. Of the nine physical therapists certified in clinical electrophysiology in 2016, five were franchise members.

To acquire the diagnostic equipment, the physical therapist purchases it directly from the manufacturer. For EMG, the most prominent equipment manufacturer is Cadwell. For MSKUS, companies like SonoSite, Phillips, and GE offer quality equipment. While there is some investment involved, a training program that expedites the time to first reimbursements can help a clinic expand the scope of their practice by tapping into a lucrative new universe of CPT codes.

The rate of reimbursement is often four times that of traditional physical therapy visits, making it a lucrative endeavor.

As with any service, marketing the ability to conduct in-house diagnostic testing can be done by a physical therapy clinic through various social media, physicians, and throughout their local market. There can also be considerable and positive word-of-mouth, which is often acknowledged as the most effective type of marketing.

A September 27, 2017 article in Musculoskeletal Care looked at Physiotherapists who utilized diagnostic ultrasound in shoulder clinics. How useful do patients find immediate feedback from the scan as part of the management of their problem? The utilization of diagnostic ultrasound by physical therapists in patients with shoulder problems concluded that patients highly rated the information gained from ultrasound imaging in a physical therapy environment and felt that it assisted them in the understanding, reassurance, and management of their problem.

According to the article, “Regarding the ability to understand their shoulder problem better and in feeling reassured about their problem, 97% of patients either strongly agreed or agreed that this was the case. Concerning the capability of managing their problem, 89% of patients strongly agreed or agreed that they felt more able to do this. In total, 96% of patients evaluated the ultrasound scan to be of very high/high value to them.”^11,12

Conclusion

It is very easy to demonize the use of opioids and demonize the use of invasive procedures like surgeries. At the same time, these procedures and medications have a place in pain treatment. Instead of using opioids in a blanket capacity, however, healthcare providers should consider alternatives like physical therapy, as the CDC suggests. By incorporating diagnostic testing into clinics, PTs can go further in providing individuals with that alternative for the treatment of pain. PTP

Dimitrios Kostopoulos, DPT, MD, PhD, DSc, ECS, is board certified in Clinical Electrophysiology with over 30 years of clinical experience. He is a clinical affiliate assistant professor for Charles E. Schmidt College of Medicine at Florida Atlantic University. He is a past member of Specialization Academy of Content Experts (SACE) for the ABPTS examination board on electrophysiology, an elected member of the Nominating Committee of the Academy of Clinical Electrophysiology of APTA, and an adjunct faculty member of Springfield College. For more information, contact [email protected].

References

1. Centers for Disease Control and Prevention. www.cdc.gov.

2. Move Forward PT web site, moveforwardpt.com. Avoid Addictive Opioids. Choose Physical Therapy for Safe Pain Management. #ChoosePT

3. Move Forward PT web site, moveforwardpt.com, article CDC Recommends Physical Therapy and Other Nondrug Options for Chronic Pain.

4. American Association of Electodiagnostic Medicine, American Academy of Phyisical et al. 2002.

5. Fowler JR, Gaughan JP, Ilyas AM. The sensitivity and specificity of ultrasound for the diagnosis of carpal tunnel syndrome: a meta-analysis. Clin Orthop Relat Res. 2011;469(4):1089-1094.

6. Hegedus EJ, Goode A, Campbell S, et al. Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests. Br J Sports Med. 2008;42(2):80-92.

7. de Jesus JO, Parker L, Frangos AJ, Nazarian LN. Accuracy of MRI, MR arthrography, and ultrasound in the diagnosis of rotator cuff tears: a meta-analysis. AJR Am J Roentgenol. 2009;192(6):1701-1707.

8. Novak CB, Lee GW, Mackinnon SE, Lay L. Provocative testing for cubital tunnel syndrome. J Hand Surg Am. 1994;19(5):817-820.

9. Volpe A, Rossato G, Bottanelli M, et al. Ultrasound evaluation of ulnar neuropathy at the elbow: correlation with electrophysiological studies. Rheumatology (Oxford). 2009;48(9):1098-1101.

10. Beekman R, Shoemaker MC, Van Der Plas JP, et al. Diagnostic value of high-resolution sonography in ulnar neuropathy at the elbow. Neurology. 2004;62(5):767-773.

11. Rubenstein SM, Pool JJ, van Tulder MW, Riphagen II, de Vet HC. A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy. Eur Spine J. 2007;16(3):307-319.

12. Lauder TD, Dillingham TR, Andary M, et al. Predicting electrodiagnostic outcome of patients with upper limb symptoms: are the history and physical examinations helpful? Arch Phys Med Rehabil. 2000;81(4):436-441.

Intended Effect of Therapeutic Laser: Photobiomodulation

By Mark Callanen, PT, DPT, OCS

Therapeutic laser therapy is a noninvasive modality that can have effects on pain and tissue repair, in both acute and chronic states of healing. Laser equipment is often confused with being a simple heating modality, which is incorrect.

Laser therapy works via the process of photobiomodulation (PBM), which is “the process of having light absorbed by endogenous chromophores (at the mitochondrial level) that elicits photophysical and photochemical events at various biological scales leading to physiological changes and therapeutic effects.”¹

PBM is the goal of all laser devices that are intended for therapeutic applications. It is not unique to any single class of laser. There are differences on how effective different light sources are in treating various conditions, but the intended effect of a therapeutic laser or LED device should not be a topic of debate outside of the concept of wanting to create a stimulatory or an inhibitory effect on the tissue being treated. This is referred to as the “biphasic approach” to laser therapy² and is an important factor to consider when treating any condition.

An Important Distinction: Class 4 Lasers

Class 4 lasers are different from other classes of lasers because they have output power greater than 0.5 watts (500 milliwatts). This helps create higher power density (irradiance), which allows for the delivery of a larger concentration of photonic energy at depth for a given wavelength.³ This is useful for a couple reasons.

PBM is very much a threshold phenomenon⁴—if enough energy is not provided to the target tissue, there will be no significant treatment effect. Higher irradiance is therefore important when treating larger individuals or when trying to impact deeper target tissues, as it is more challenging to get sufficient amounts of light to the intended target.

Treating with higher irradiance levels has unique effects on nerve tissue, specifically pain signaling from peripheral C and A-delta fibers^4,5,6 which are responsible for chronic and acute pain signals from the periphery. There are several mechanisms responsible for reducing pain levels when sufficient irradiance is applied to these nerves, but the net effect of treating these sensory nerves with higher irradiance is that true analgesia can be created via PBM in a matter of minutes.⁴

Short-term pain relief is the result of temporary neuroplastic changes to the axon,4,6 whereas lasting pain relief involves general reduction of the “inflammatory soup” present at the peripheral nerve endings.^4,6 Treatment of peripheral nerves has also been shown to down regulate CNS factors involved with central sensitization such as increasing the levels of serotonin, decreasing NMDA activity (#), and increasing endogenous opioid levels at the dorsal horn.⁴ These findings are leading to an increased interest from the medical community in incorporating laser therapy into pain management plans of care.

If you are currently using a laser in your clinic to address pain and inflammation, there are several things you can do to maximize your outcomes. Therapists should have an understanding of tissue dosing and how different energy and power levels impact tissue(s). Understanding the bi-phasic nature of PBM will help with making informed decisions when treating different conditions at different stages of the tissue-healing cycle.

Light Source Makes a Difference

Additionally, know your light source! Know the wavelengths being used, as this impacts depth of penetration. Is the light coming from a laser, a LED, or a combination of the two? There are significant differences between the two. Due to their physical characteristics, LEDs are generally not as effective at treating deeper tissues and do not have the ability to create irradiance levels that provide the quick analgesia mentioned previously.⁷ Understanding some of these constraints will help shape treatment expectations.

Finally, it is beneficial to know, at a minimum, the power output of your equipment and how to calculate both the power density (irradiance) and total energy density (J/cm2) that is being provided by your device. This information is important as it correlates with the dosage required to maximize PBM for a given condition. Higher-quality PBM studies will clarify several treatment parameters which will include both the power and energy densities that were used in the study. Clinicians will need to know if their equipment can replicate the same parameters in order to expect the same outcomes.

As the research related to PBM grows, the question of “does it work?” is being replaced with “how exactly does it work?” and “what is the recommended dosage for that condition?” Knowing the basics regarding laser terminology and the associated physics will go a long way toward becoming an educated consumer about this topic.

References

1. Anders JJ, Lanzafame RJ, Arany PR. Low-level light/laser therapy versus photobiomodulation therapy. Photomed Laser Surg. 2015;33:183-184.

2. Huang YY, Chen AC, Carroll JD, Hamblin MR. Biphasic dose response in low level light therapy. Dose Response. 2009;7(4):358–383.

3. Enwemeka C. Intricacies of dose in laser phototherapy for tissue repair and pain relief. Photomed Laser Surg. 2009;27(3):1-7.

4. Cotler HB, Chow RT, Hamblin MR, Carroll J. The use of low level laser therapy (LLLT) for musculoskeletal pain. MOJ Orthop Rheumatol. 2015;2(5).

5. Chow R, Armati P, Laakso EL, Bjordal JM, Baxter GD. Inhibitory effects of laser irradiation on peripheral mammalian nerves and relevance to analgesic effects: a systematic review. Photomed Laser Surg. 2011;29(6):365-381.

6. Holanda VM, Chavantes MC, Wu X, Anders JJ. The mechanistic basis for photobiomodulation therapy of neuropathic pain by near infrared laser light. Lasers Surg Med. 2017;49(5):516-524.

7. Moskvin SV. Only lasers can be used for low level laser therapy. Biomedicine (Taipei). 2017;7(4):22.