Physical Therapy an Alternative to the High Risks of Methadone

Tallahassee, Florida, August 18, 2008 – A recent investigative report1 published in the New York Times highlights the alarming increase in methadone prescriptions for the treatment of chronic spinal pain.  The result has been a shocking increase in methadone related deaths.  Physical therapists can play a role in providing patients and physicians with an alternative to dangerous pain medications like oxycodone and methadone.

Methadone was once limited to use in addiction treatment centers to replace heroin, but today it is frequently given out by physicians to manage spine and joint pain.  The Drug Enforcement Administration noted that from 1998 to 2006, the number of methadone prescriptions increased by 700 percent.  “Many legitimate patients, following the direction of their doctor, have run into trouble with methadone, including death,” noted pain specialist Dr. Howard A. Heit from Georgetown University.  Florida alone, which keeps detailed data, listed methadone as a cause in 785 deaths in 2007, up from 367 in 2003.

“These are senseless deaths,” said Dr. Timothy Flynn of Regis University in Denver, CO, and President of the American Academy of Orthopedic Manual Physical Therapists (AAOMPT).  “Patients should be aware that these medications are not the best option to reduce the symptoms of spinal pain. Research has shown that early movement and treatments like exercise and spinal manipulation offer strong benefits to spine pain and disability.”  “The medical management of spinal pain in this country is a failure,” continued Flynn, “we too often initiate prescription drug therapy before choosing safe and effective alternatives.”  Flynn suggests that patients seek out physical therapists as a first-line treatment for these conditions.

A February 2008 report published in the Journal of the American Medical Association reports that from 1997 to 2005, pharmaceutical expenditures for the management of low back pain increased by 171% while the rate of good outcomes fell.  “All the imaging we do, all the drug treatments, all the injections, all the operations have some benefit for some patients,” said Richard A. Deyo, a physician at Oregon Health & Science University in Portland and a coauthor of the report.  “But I think in each of those situations we’ve begun using those tests or treatments more widely than science would really support.”

For more on the benefits physical therapists can provide in the management of spinal pain, contact your nearest physical therapist or visit the American Academy of Orthopaedic Manual Physical Therapists website at www.aaompt.org.  AAOMPT represents physical therapists by promoting excellence in orthopaedic manual physical therapy practice, education and research. 

Dr. Richard Deyo, MD, MPH will be the key note speaker at AAOMPT’s Annual Conference in Seattle this November.  The conference theme will focus on pain management and physical therapists’ role in this important area of care.

Myofascial pain syndrome is a common muscle pain condition that is often overlooked in medical and clinical practice settings today. It is often characterized as a chronic pain condition and confused with fibromyalgia syndrome. In reality, myofascial pain can be acute or chronic in nature.  Myofascial pain is characterized by the presence of myofascial trigger points, which are hyperirritable contraction knots found in tight bands of muscles. Trigger points can cause localized pain or can refer pain to other areas of the body. A muscle that is burdened with trigger points could lose its flexibility, strength and coordination which may contribute to the formation or sustenance of other musculoskeletal problems. Myofascial trigger points are treated by various medical practitioners in numerous ways, including by injections, dry needling, manual techniques, massage therapy, stretching, and relaxation techniques.

Dry needling is an effective and efficient therapy method for the treatment of myofascial trigger points.  Trigger point dry needling is performed by medical doctors, physical therapists, nurses, chiropractors, and dentists that are specifically trained in the technique. The approach is based on Western anatomical and physiological principles. The technique utilizes fine solid acupuncture needles to release trigger points in muscle, but in all other aspects it is different than traditional acupuncture. Other terminology used to describe similar techniques to dry needling includes intramuscular stimulation (IMS) and twitch-obtaining intramuscular stimulation.

Dr. Janet Travell first described trigger point injections in the early 1940’s. Injections are performed by injecting trigger points primarily with saline or analgesics. Through the years it has been shown that it is not the substance that is being injected that is providing the therapeutic benefit, but rather the mechanical stimulus of the needle hitting the trigger point. When a needle tip hits a trigger point, a characteristic ‘local twitch’ is noted by the clinician and the client. This local twitch is involuntary. It has been shown that the elicitation of local twitch responses is the most important aspect in obtaining a successful therapeutic outcome for trigger point deactivation. There are a number of hypotheses as to the reasons why dry needling works. Dry needling and the subsequent local twitch responses may mechanically disrupt the contracted nature of the trigger point. Dry needling stimulates certain sensors in the body which modulate pain signals. Dry needling and the subsequent local twitch responses can cause local biochemical changes and result in an increase of blood flow in the trigger point area.

The benefits of trigger point release through dry needling include a decrease in the tightness and the pain associated with a particular muscle. Often times an immediate improvement is noted. Dry needling is tolerable for most, but not all people. A limited amount of muscle soreness is to be expected for 1-2 days, after which the soreness resolves. Dry needling is never used as an isolated treatment; it is followed by myofascial release and soft tissue work to minimize soreness and to maximize connective tissue flexibility. Other important aspects of musculoskeletal improvement of pain and function requires addressing possible contributing factors which includes the presence of joint or spinal dysfunction, postural imbalances, poor coordination of movement and poor posture and body mechanics with activities of daily living.

Not all medical professionals are trained in the assessment or treatment of myofascial trigger points. Trigger point dry needling requires highly specialized training. One must be adept at finding trigger points before one can attempt to treat them. If you have suffered of pain or tightness of muscular origin, I would urge to consider the possibility of trigger point dry needling as a treatment option. It has made a world of difference in many people’s lives.

Most everyone has heard the saying “no pain, no gain” when it comes to exercise. This may be true in terms of a healthy individual and when it refers to the muscle burn sensation that accompanies exercise. It may also be true in terms of the two days of soreness that follows the start or progression of a strengthening exercise program, or that follows the performance of an activity that has not been performed in a while. This soreness is better known as “delayed-onset muscle soreness” and is a normal part of the adaptation process of muscle breakdown.

“No pain, no gain” is not true when one has been injured. When one is recovering from an injury it is not wise to exercise with pain. When one is performing their rehabilitation program, one should only exercise in a pain-free range. If there is always a bit of pain present, as it is true after an injury or surgery, then you should never do exercise that creates more pain or increases your pain response. The increase of pain perception is the body’s way of letting you know you are overdoing things and that some tissues are not able to handle the stress that is put on them. The soft tissues (tendons, ligaments, muscles, and fascia) involved become weak and over-stressed.

Pain is a subjective feeling that we all have experienced at one time or another. We expect that we are going to experience pain after an injury or trauma. However, if there is no presence of pain during exercise we may think that there is nothing to worry about. This may not always be the case. Pain during exercise is the body’s way of telling us whether we are exercising too hard or overstressing our bodies. But just because pain is not present, does not mean that we may not be doing harm. For instance, a sedentary or deconditioned individual may not experience a pain response during exercise. However, then one day they find they have back pain or neck pain due to a lack of muscle endurance or some other musculoskeletal problem. For this reason, many people move into pain patterns without any apparent reason or trauma.

In summary, exercise should be performed without any increase in pain. Therapeutic exercise is utilized to promote healing, increase metabolism, and introduce gentle controlled loads so that the soft tissues can adapt to normal forces. Periodic maintenance through exercise can prevent non-traumatic pain patterns from occurring. It is important to give plenty of feedback to your physical therapist or other health professional so he or she can monitor and make any adjustments to your exercise program.

At least one member of nearly half (44%) of America’s households suffers from chronic pain. Within Maryland, 49% suffer from pain on a monthly basis and 40% experience pain almost daily.

The impact of chronic pain is devastating for the individual as well as for society. Persons with chronic pain suffer physical, psychological, and social detriments. Many say that their pain disturbs their ability to sleep and their productivity at work. It interferes with the ability to participate in daily home, leisure, and recreational activities. It can negatively interfere with sexual relations as well as relations with family and friends. Chronic pain sufferers describe feeling anxious, irritable, or depressed as a consequence of their pain. In severe cases, pain sufferers describe feeling helpless and alone. Chronic pain may be the single most costly medical problem in the U.S.

Annual costs for medical expenses, lost income, and lost productivity are estimated to exceed $50 billion. The International Association for the Study of Pain defines pain as: “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described by the patient in terms of such damage.” Acute pain is indicative of inflammation and tissue damage resulting from injury, illness or recent surgery. It is short lived and usually subsides after the underlying cause and subsequent inflammation has resolved.

On the other hand, chronic pain can last for months or years. Chronic pain may start as a progression of acute pain after an injury or illness, even perhaps after the original problem has resolved. It can also be as a consequence of ongoing sources of pain related to medical conditions such as low back pain, cancer, arthritis, headaches, neuralgias, neuropathies and other pain disorders. In chronic pain, constant firing of pain signals occurs in the nervous system.

Over time, this persistent bombardment of pain signals can actually change the structure and function of the central nervous system thereby lowering the threshold of pain. For example, an individual’s perception of a normal painful stimulus can actually be perceived as extremely painful or an individual’s perception of a non-painful stimulus can actually be perceived as painful. These are only some of the examples of the complexities of chronic pain.

A skilled physical therapist will initially evaluate and treat involved painful nerves, muscles, and joints to decrease pain and improve function. This may lead to a decrease number of pain signals firing in the central nervous system and hopefully contribute to breaking of the pain cycle. Physical therapy can also be helpful in managing chronic pain by restoring normal movement patterns, developing a realistic exercise program, and providing education regarding goal setting, pacing of activity and other self management techniques.

Although the general medical approach to chronic pain is to manage the problem, there are occasions in which the underlying cause was not addressed but once treated may result in a significant improvement in one’s pain. An example of a chronic pain condition often overlooked is Myofascial Pain Syndrome, which describes pain due to sensitive knots in muscles called ‘Trigger Points’.

Despite the fact that chronic pain is a medically complex problem and can influence all facets of an individual’s life, a multidisciplinary treatment approach can alleviate one’s suffering in the management of the condition.