Pain Management in Physical Therapy.

Pain Management in Physical Therapy The aims of this book are to provide up-to-date anatomical and physiological bases for pain, some knowledge of pharmacological pain management, an understanding of the role of the physical therapist in the management of pain, and a review of some special areas in which physical therapy has been particularly effective in pain management. In order to accomplish these tasks, the book provides a review of the neuroanatomy and neurophysiology of pain pathways and how nociceptive input might be modulated, both pharmacologically and physically. This section is followed by a lengthy section that concerns various physical modalities used in pain management, including heat, cold, transcutaneous electrical nerve stimulation, acupuncture, connective tissue massage, exercise, and mobilization. Areas of special interest include pain management after surgery, in terminal care, and in obstetrics and gynecology.

In general, the book is well organized and germane, covering important topics in a practical and useful manner. Of special merit is the attention given to thorough evaluation of patients before treatment so that specific problems can be identified and managed appropriately. The contributions have been well coordinated, so there is little unnecessary repetition of material and no obvious conflict in terminology or interpretation.

The book has two problems that troubled me. The first relates to the level of coverage of different topics. The book is not intended as a neuroscience or procedures text, yet enough depth must be provided to build a logical management rationale. Presumably physical therapists are the intended audience for the book. Consequently, coverage of topics with which physical therapists are unfamiliar should be greater than for topics with which they have substantial expertise. The excessively detailed descriptions of commonly used heating and cooling agents are unnecessary.

The more serious problem is the lack of evidence to support the contentions of the various authors. The book is replete with opinion and promotes a continuation of commonly held beliefs, especially when dealing with interferential current. The reader and the professional would be better served if the authors described presumed mechanisms of pain relief with the techniques included in the book and cited research to detail the evidence on which those presumptions are based. Any new textbook in physical therapy must move the field forward either by using available research to support claims or by identifying a research agenda to provide such evidence. The contributions to this book only rarely provide evidence of research support, and in only one instance does a contribution outline even the most rudimentary research agenda. One contributor actually detailed a litany of reasons why research on mobilization could not be done.

Some chapters in the book contain errors that alter the interpretation of the neurophysiological principles. For example, one contributor states that heat and cold sensations are carried in the large myelinated fibers thus making thermal stimuli effective in closing the spinal gate.

Because these sensations are actually carried in small fibers, spinal gating cannot be the mechanism of pain relief.

There are also omissions and organizational issues that caused me concern. Interferential current was included in the chapter on shortwave diathermy and ultrasound rather than in the chapter on TENS. Interferential current is an electrical current in the same approximate frequency range as those used in TENS, so this organization is curious. The discussion of TENS itself is limited to chronic pain, with no mention of TENS use for acute pain. There is no discussion of the role of electromyographic biofeedback in pain management, and the discussion of mechanical traction consists of one short paragraph in the chapter on mobilization.

The book could serve as an introductory survey of the topic and has many practical suggestions of care. Overall, the authors have met their goals of reviewing the neuroanatomy and neurophysiology of pain and providing an overview of pharmacological management. Although they have achieved their goal of discussing the role of physical therapy in pain management, they could have served the profession better by citing needed empirical support of their contentions and advancing a research agenda.